Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the orthopedic mens shoes oxford (L3219). 
 
You asked the Plan to pre-approve the foot orthotics. You say that please reconsider this request as it is painful 
to walk, and you just had surgery on your little toe because the present show insert has worn out. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve the orthopedic mens shoes oxford 
(L3219).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a carotid doppler. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says on appeal, the requesting cardiologist states that the testing is not needed at this time, 
and there is no medical necessity for this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that a request is made for authorization for carotid doppler examination in this asymptomatic patient with 
no history of bruit on physical examination. The patients physician actually withdrew the request for carotid 
doppler imaging. At this time the requested carotid doppler imaging would not be considered medically 
necessary in this patient's clinical management based on the submitted documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a carotid doppler.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the ground mileage (A0425) provided on January 10, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that the transport was reimbursed after the 
reconsideration of the corrected claim. You say that the mileage was denied as a duplicate. You also say that 
this should be covered too. The Plan denied your request. The Plan says that the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the file does not support that plan's denial. Therefore, we decided 
that the Plan has to pay for the ground mileage (A0425) provided on January 10, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a targeted genomic sequence analysis panel. 
 
You asked the Plan to pre-approve the testing. You say that there has been numerous cancers, including 
melanoma, pancreatic duodenal adenoma, multiple squamous cell carcinoma. The Plan denied your request. 
The Plan says this test does not have Food and Drug Administration (FDA) approved or clearance as a 
companion in vitro diagnostic.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records do not document that the requested testing has Food & Drug Administration 
(FDA) approval or clearance as a companion in vitro diagnostic, and an FDA-approved or -cleared indication 
for use in this patient's cancer, as required by the NCD.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a targeted genomic sequence analysis panel.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says the records do not 
show the enrollee requires daily skilled nursing or skilled therapy in a SNF setting, the services needed are 
custodial care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on June 20, 2022. 
 
You asked the Plan to pay for ambulance services. You say that services were rendered prior to hospice 
admission on June 20, 2022. The Plan denied your request. The Plan says Original Medicare would be 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on June 20, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 2, 2022. 
 
You asked the Plan to pay for the physician's services. You say that you had no control that this provider is 
out-of-network. The Plan denied your request. The Plan says the service was provided from a provider who 
chose not to receive Medicare funds. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
physician's services provided on August 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from June 
17, 2021, to June 23, 2021. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says no clinical evidence was presented to support 
the diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 682. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that in this case, documentation indicated that the patient had underlying chronic kidney disease and no 
baseline was provided. During the admission, the creatinine ranged from 2.8 to 3.6. The creatinine was not 1.5 
times or more from the imputed baseline. In addition, while the creatinine did increase by more than 0.3 mg/dL 
within 48 hours, this criterion does not apply to patients with chronic kidney disease. Furthermore, review 
found no documentation of a decrease in urine output. The review has determined that the documentation did 
not support diagnosis code N17.9 - acute kidney failure, unspecific. The records support DRG 291 in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from June 17, 2021, to June 23, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 9, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service November 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12001 billed for date of service August 7, 
2022. 
 
You asked the Plan to pay for procedure code 12001. You say that this code should be separately paid. The 
Plan denied your request. The Plan says payment for code 12001 is bundled into payment for code 28510.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that code 12001 is a column II code to column I code 28510. Modifier -51 was 
used, but this is not a modifier that can be used to bypass the edit. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
12001 billed for date of service August 7, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the magnetic resonance imaging (MRI) (70553) provided on April 15, 
2022. 
 
You asked the Plan to pay for an MRI. You say that this should be covered. The Plan denied your request. The 
Plan says that this service was not authorized. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  The Plan contract states that a referral or prior authorization is not required for care from out-of-
network providers. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the service at issue was denied because it was not 
authorized, but the Plan contract states that authorization is not required for services provided by out-of-
network providers. The Plan has not provided a valid denial reason for the service at issue. Therefore, we 
decided that the Plan has to pay for the magnetic resonance imaging (MRI) (70553) provided on April 15, 
2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 25, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this claim was denied in error. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service October 25, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for procedure code A0425 billed for date of service October 19, 2022. 
 
You asked the Plan to pay for procedure code A0425. You say that these services were necessary and were 
reported correctly. The Plan denied your request. The Plan says that the number of units billed exceeds the 
maximum allowed on a single line. 
 
The Plan must follow Medicare rules. Medicare rules say that for codes with an MAI of 1, each line of a claim 
with that HCPCS/CPT code will be separately adjudicated against the MUE value for that code. A single line 
may not exceed the MUE for that code, but additional lines for additional units may be reported with an 
appropriate modifier. 
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. This means that no more 
than 250 units of A0425 may be reported on one line. The Plan denied this claim stating that 405 units have 
been billed. However, the unit number for this claim includes a decimal point and clearly shows that you billed 
40.5 units of this code, which is less than the MUE. It is appropriate to report mileage units of less than 100 
miles to the nearest tenth of a mile. Based on this information, we decided that Medicare rules for coverage of 
procedure code A0425 have been met. Therefore, we decided that the Plan has to pay for procedure code 
A0425 billed for date of service October 19, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliance (E0673) provided May 12, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliance (E0673) provided May 
12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vehicle conversion for wheelchair accommodation. 
 
You asked the Plan to pre-approve the vehicle conversion. You say that the enrollee has a regular wheelchair 
and needs a vehicle conversion to get around to doctor appointments and other activities. The Plan denied your 
request. The Plan says the requested service does not serve a purpose that is primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve vehicle conversion for wheelchair accommodation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for date of service September 5, 
2022. 
 You asked the Plan to pay for procedure code 85060. You say that this service was necessary and was billed 
correctly. The Plan denied your request. The Plan says this service was not billed in accordance with Medicare 
guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that no payment is recognized for code 85060 
furnished to hospital outpatients or non-hospital patients.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 85060 have not been met. Specifically, the record shows that this service was 
furnished to an enrollee in an outpatient hospital (Place of Service code 22) setting. Therefore, we decided that 
the Plan does not have to pay for procedure code 85060 billed for date of service September 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automatic blood pressure monitor. 
 
You asked the Plan to pre-approve these services. You say that you are suffering from low blood pressure. The 
Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a non-segmented pneumatic compressor (E0650) non-segmental 
pneumatic appliance for use with pneumatic compressor, half arm (E0655) and orthotics management and 
training, upper extremities, lower extremities and/or initial orthotics encounters, each 15 minutes (97760) 
provided June 24, 2022, to July 13, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. You say that please reprocess 
the claim. The Plan denied your request. The Plan says that this item is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. in this case specific records or information was required to substantiate the Plans 
denial. The required information was missing from the original file. A request for information was sent to the 
health plan on February 6, 2023, with a due date of February 7, 2023. As of the date of this letter, the Plan has 
not responded to our request and/or submitted the missing information. Therefore, we decided that the Plan has 
to pay for a non-segmented pneumatic compressor (E0650) non-segmental pneumatic appliance for use with 
pneumatic compressor, half arm (E0655) and orthotics management and training, upper extremities, lower 
extremities and/or initial orthotics encounters, each 15 minutes (97760) provided June 24, 2022, to July 13, 
2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.