Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assay of ferritin (82728) and iron binding capacity (83550) 
provided on December 13, 2021. 
 
You asked the Plan to pay for laboratory tests. You say that these services were medically necessary and are 
supported in the record. The Plan denied your request. The Plan says the diagnoses on this claim do not support 
the medical necessity of these services. 
 
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 pay for laboratory tests. Our reviewer says that the 
requested tests were not medically necessary based on the documentation provided. Our physician reviewer 
found that the enrollees conditions related to these tests were submitted as follows: abdominal distension 
(gaseous) (R14.0), other fatigue (R53.83), pure hypercholesterolemia, unspecified (E78.00), menopausal and 
female climacteric states (N95.1), other specified metabolic disorders (E88.89), Vitamin D deficiency, 
unspecified (E55.9), Vitamin deficiency, unspecified (E56.9) and other long term (current) drug therapy 
(Z79.899). There was no specific clinical rationale for the requested laboratory studies. There was no history of 
iron deficiency anemia or issues related to iron metabolism. The review has determined that the requested tests 
were not medically necessary per 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 laboratory tests have not been met. Therefore, we decided that the Plan does not 
have to pay for assay of ferritin (82728) and iron binding capacity (83550) provided on December 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87491, 87496, 87511, 87529, 87532, 87563, 
87591 and 87661 billed for date of service February 25, 2022. 
 
You asked the Plan to pay for procedure codes 87491, 87496, 87511, 87529, 87532, 87563, 87591 and 87661. 
You say that this testing was necessary and is supported as billed. The Plan denied your request. The Plan says 
these services are not supported as billed. 
 
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, CPT codes 87491, 87496, 87511, 
87529, 87532, 87563, 87591 and 87661 all report tests for various sexually transmitted infections (STIs). 
 We asked our coder 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 procedure codes 87491, 87496, 87511, 87529, 87532, 87563, 
87591 and 87661. Our reviewer says that these services are not supported in the records provided. Our reviewer 
found the medical documentation does not support STI testing as there were no results provided for these tests. 
The urinary tract infection (UTI) testing was extensive and conclusive; however, there are no STI results and 
therefore we are unable to verify if STI testing was actually completed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87491, 87496, 87511, 87529, 87532, 87563, 87591 and 87661 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87491, 87496, 
87511, 87529, 87532, 87563, 87591 and 87661 billed for date of service February 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 3 standard, multiple power 
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds and accessories (K0861, 
K0108, E2311, E2313, E2377, E2300, E1012). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you are requesting review 
of the addendum from the physical therapy report to reconsider approval of the enrollee's wheelchair. The Plan 
denied your request. The Plan says the enrollee does not have medical need for the multiple power options 
included with the requested group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  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 a power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found there is 
documentation that the enrollee has a personal mobility deficit that impairs participation in mobility related 
activities of daily living such as toileting, feeding, grooming, and bathing in customary locations within the 
home. The enrollee's mobility deficit cannot be helped using a walker, cane, or manual wheelchair due to her 
level of weakness and instability. Provided records document that the enrollee has 3/5 to 3+/5 upper extremity 
strength with normal right upper extremity range of motion thus indicating she has adequate upper extremity 
strength and function to operate the wheelchairs power options with their own switches. The requested power 
seat elevation feature is statutorily non-covered as it serves no primary medical purpose. Provided records do 
not document she has a musculoskeletal condition or the presence of a cast or brace which prevents 90-degree 
flexion at the knee or has significant edema of the lower extremities that requires an elevating leg rest. 
Provided records do not support that she is high risk for skin breakdown, has a history of pressure ulcer(s) or 
has had skin flap surgery. Records do not document the enrollee performs bladder self-catheterization and is 
unable to transfer independently or has increased muscle tone or spasticity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair, group 3 standard, multiple power option, 
sling/solid seat/back, patient weight capacity up to and including 300 pounds and accessories (K0861, K0108, 
E2311, E2313, E2377, E2300, E1012).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88360) provided on January 23, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 88360 is not supported in the medical record. Specifically, the code billed has a 
professional component / technical component indicator of 1. The service was provided in the inpatient setting. 
A required modifier (26) was missing. Based on this information, we decided that Medicare rules for coverage 
of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(88360) provided on January 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-sterile gloves (code A4927) you purchased from June 
30, 2022, to August 1, 2022. 
 
You asked the Plan to pay for the gloves. You say that you have issues with incontinence, so these gloves are 
medically necessary. The Plan denied your request. The Plan says these gloves are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that non-sterile gloves are only covered when used as 
a dialysis supply.  You did not purchase these gloves for dialysis purposes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the gloves have not been met. Therefore, we decided that the Plan does not have to pay for non-
sterile gloves (code A4927) you purchased from June 30, 2022, to August 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient visit provided on May 25, 2022. 
 
You asked the Plan to pay for the outpatient visit. You say that the services were provided in good faith. The 
Plan denied your request. The Plan says the Plan has to pay for care from out-of-network providers only in 
cases involving emergencies, out of area urgent care and pre-approved care. The Plan says that the Plan has 
also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an outpatient visit provided on May 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 27, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 7, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on April 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need a portable oxygen 
concentrator when traveling to a non-local area. Your current equipment requires you to haul 2 to 3 tanks each 
time and it is very difficult to carry these tanks especially when you are gone for the day for an extended period 
of time. You were recommended to have a backpack portable concentrator. The Plan denied your request. The 
Plan says you received oxygen starting on May 21, 2021. There is no clinical documentation indicating that 
your current portable oxygen equipment is in disrepair or is no longer meeting your oxygen needs. The 
requested portable oxygen concentrator is a convenience item as your current oxygen equipment is meeting 
your oxygen needs. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you received portable oxygen equipment on May 21, 2021. Portable oxygen equipment 
serves the same purpose as a portable oxygen concentrator. Specifically, it is considered a convenience item as 
your current equipment is serving your oxygen needs. Therefore, we decided that the Plan does not have to pre-
approve a portable oxygen concentrator (E1392).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from an IRF to optimize his 
level of functioning prior to returning home. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for supplies for international normalised ratio (INR) at-home testing 
(G0249) billed for date of service November 15, 2021. 
 
You asked the Plan to pay for supplies for INR at-home testing. You say that the items at issue are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that the request exceeds the maximum 
allowed units in the designated time period. 
 
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 Plan's denial is predicated on a rule stating that the services at 
issue cannot be billed more than once a week. However, the next billed date of service mentioned by the Plan is 
a week or more after the date of service at issue in this case. It is the Plan's responsibility to substantiate its 
denial with evidence. In this case, the Plan's denial has not been substantiated, so we must find in your favor. 
Therefore, we decided that the Plan has to pay for supplies for INR at-home testing (G0249) billed for date of 
service November 15, 2021.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9501 billed for dates of service March 31, 
2022, to April 9, 2022. 
 
You asked the Plan to pay for procedure code S9501. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9501 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9501 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9501 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9501 billed for dates of service March 31, 2022, to April 9, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on July 18, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that payment is not 
allowed for this procedure code because it is inconsistent with the place of treatment submitted. 
 
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. The Plan has not shown that the enrollee was an outpatient on the date of service 
in question, nor did it provide evidence to support that the reported place of service code is inappropriate in this 
case. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that 
the Plan has to pay for the services provided on July 18, 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 pay for the genetic testing provided on May 25, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this is medically necessary testing that is 
covered by Medicare. The Plan denied your request. The Plan says the claim for this molecular pathology 
testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the requested epidural steroid 
injection is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested epidural steroid injection. 
 
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 an epidural steroid injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the LCD requires 3 months of 50% pain relief. The 3-month mark has not 
been reached and so this request is premature. The request, at this point, is deemed not medically reasonable 
and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Montegrity. 
 
You asked the Plan to pre-approve Montegrity. You say that this is the only medication that has been effective 
for the enrollee. The Plan denied your request. The Plan says coverage of this medication is the responsibility 
of the enrollee's prescription drug plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Montegrity.  
 
Benefits for Montegrity may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.