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

 
We decided that the Plan does not have to pre-approve a Group 3 heavy-duty power wheelchair with single 
power option (K0858) and related accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair and related accessories. You say that the 
requested items are a medical necessity for you. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
The Plan follows 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 a Group 3 power wheelchair and related 
accessories. Our reviewer says that the requested items are not medically reasonable and necessary in this case. 
Our physician reviewer found that you have a mobility deficit. The documentation states that you are 
independent in dressing, feeding, meal prep with set up, but you have ataxia, fatigue and left-sided weakness 
and cannot complete home management easily. The documentation states that you can use a walker for short 
distances.  The documentation does not reveal you are at a high risk for developing a pressure sore. You are 
independent for transfers and there is no documentation of intermittent catheterization. You do not have 
increased tone or spasticity that needs to be managed with a power seating system. 
 
 
  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 Group 3 power wheelchair and related accessories have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 heavy-duty power wheelchair with 
single power option (K0858) and related accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous airway pressure (CPAP) device (E0601) provided 
May 20, 2022, to June 20, 2022. 
 You asked the Plan to pay for the CPAP device. You say that you do not want to transfer the balance to the 
enrollee because this should be covered by the insurance. The Plan denied your request. The Plan says the 
service is a covered benefit, but the enrollee has exceeded the frequency set by Medicare. 
 
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 find that CPT code E0601 is not supported in the medical record. Specifically, per the capped 
rental item, DME MACs continue to pay rental fees not to exceed a period of continuous use of 13 months and 
ownership of the equipment passes to the beneficiary. Based on this information, we decided that Medicare 
rules for coverage of the CPAP device have not been met. Therefore, we decided that the Plan does not have to 
pay for continuous airway pressure (CPAP) device (E0601) provided May 20, 2022, to June 20, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72141 billed for date of service June 29. 
2022 
 You asked the Plan to pay for procedure code 72141. You say that review the medical records and reprocess 
the claim for payment. The Plan denied your request. The Plan says payment for code 72141 is bundled into 
payment for code 72156. 
 
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 72141 
is a column II code to column I code 72156. This claim has not been billed with an appropriate modifier 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 72141 billed for date of service June 29. 2022
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography angiography (CTA) of the abdomen. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that follow-up imaging is only supported once per three years. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 medically reasonable and necessary. Our physician reviewer found that the enrollee has a 
splenic artery aneurysm. The last scan on 7/14/20 showed a stable 1.6cm aneurysm. The report recommended 
follow-up in a year. It has been 2.5 years since the CTA, and the enrollee is frail and has coronary stents. The 
request for a follow-up scan of the known splenic artery aneurysm is reasonable and well overdue. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve computed tomography angiography (CTA) of the abdomen.  
 
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 pre-approve a pneumatic compressor and segmental pneumatic 
appliance for use with pneumatic compressor to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor and segmental pneumatic appliance for use with 
pneumatic compressor to be provided by an OON provider. You say that the services are necessary. The Plan 
denied your request. The Plan says there are in-network providers that are able to provide these services. 
Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor and segmental pneumatic appliance for use with pneumatic compressor to be provided 
by an out-of-network (OON) provider.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for emergency department services provided on from June 20, 2022, to 
June 23, 2022. 
 
You asked the Plan to pay for emergency department service. You say that this provider is in-network. The 
Plan denied your request. The Plan says that the service/equipment/drug is not covered under the patient's 
current benefit plan. 
 
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 has not substantiated their denial with a rule. Therefore, 
we decided that the Plan has to pay for emergency department services provided on from June 20, 2022, to 
June 23, 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 laboratory testing performed by the hospital on April 25, 
2022. 
 
You asked the Plan to pay for the laboratory testing. You say that this was denied as duplicate incorrectly. The 
Plan denied your request. The Plan says this claim is a duplicate of a paid claim and was correctly denied. The 
original claim denied as there was a corrected claim for the same services being processed, which then was 
paid. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 26, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the laboratory testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory testing performed by the hospital on 
April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a thoracentesis procedure (32555) billed for date of service 
July 3, 2022. 
 
You asked the Plan to pay for a thoracentesis procedure. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers or suppliers shall use anatomic 
modifiers and report procedures with differing modifiers on individual claim lines when appropriate.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a thoracentesis procedure have not been met. Specifically, the procedure code at issue has not been 
reported with an anatomic modifier. Therefore, we decided that the Plan does not have to pay for a 
thoracentesis procedure (32555) billed for date of service July 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transurethral waterjet ablation of prostate, including 
control of post-operative bleeding, including ultrasound guidance, complete (0421T). 
 
You asked the Plan to pre-approve a transurethral waterjet ablation. You say that the service requested is much 
less invasive and better to deal with urinary obstruction. It has a better recovery process, more modern and 
well-approved procedure. The Plan denied your request. The Plan says there was no indication from the 
medical records whether symptoms persist despite maximal medical management. 
 
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 a transurethral waterjet ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have urinary retention managed self-catheterization 3 times daily. You 
also have prostate cancer with bone metastasis managed with leuprolide. The requested procedure is 
not considered reasonable and necessary in this case. The LCD does not cover this procedure when there is 
known or suspected prostate cancer. 
 
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 transurethral waterjet ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a transurethral waterjet ablation of prostate, including control of post-
operative bleeding, including ultrasound guidance, complete (0421T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92929 billed for date of service July 21, 
2022. 
 
You asked the Plan to pay for procedure code 92929. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 92929 is considered bundled and not separately 
payable. 
 
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 92929 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 92929 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 92929 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 92929 billed for date of service July 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74160 billed for date of service August 24, 
2022. 
 
You asked the Plan to pay for procedure code 74160. You say that this service was medically necessary. 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 cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 74160 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 74160 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 74160 billed for date of service August 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) additional home skilled nursing visit(s) (G0299). 
 
You asked the Plan to pre-approve additional home health services. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the services are not medically necessary. 
 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health services. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found 
provided records do not document any acute or unstable medical conditions or changes in medication or 
treatment which would necessitate any further skilled nursing visits beyond what have already been approved. 
Records document you have been educated on your disease process and medications. No medical notes from 
your treating physician are provided documenting an order or need for additional skilled nursing services. 
Records do not document the need for intravenous medications, new tube feeding or ostomy care or complex 
wound care. Records indicate you reside in an assisted living facility and will be moving to a memory unit 
where you will have supervision and caregivers available. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional home health services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve six (6) additional home skilled nursing visit(s) (G0299).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ziextenzo. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the Ziextenzo is being requested for 
prevention of chemotherapy-induced febrile neutropenia. The enrollee has not tried and failed the Plan's 
required drugs, a trial of at least two of Neulasta, Fulphila, or Udenyca. The records do not show that the 
required drugs would be contraindicated or less effective; therefore, Ziextenzo is not reasonable or medically 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ziextenzo.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulator supplies, 2 lead, per month, (e.g., TENS, 
NMES) (A4595) and lead wires, (e.g., apnea monitor), per pair (A4557) provided June 13, 2022. 
 
You asked the Plan to pay for electrical stimulator supplies. You say that the prescribing physician 
recommends an extended lifetime use of equipment as the enrollee was diagnosed with chronic pain and 
compromised mobility without the option for surgical correction. The Plan denied your request. The Plan says 
evidence of misrepresented services 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the Plan made outreach to the ordering providers 
indicated on the claim form and the Plan confirmed that the denied items were not ordered by the provider. The 
provider indicated that they have not seen this enrollee since August 2016. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for electrical stimulator supplies, 2 lead, per month, (e.g., TENS, NMES) (A4595) 
and lead wires, (e.g., apnea monitor), per pair (A4557) provided June 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 & 99233 billed for date of service 
May 24, 2022 to June 3, 2022. 
 You asked the Plan to pay for procedure code 99232 & 99233. You say that this service is medically necessary. 
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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99232 & 99233 is 1. The MAI value for this code is 3. You billed 2 units 
of this code, exceeding the MUE. You did not provide all the required evidence showing that the excess units 
were actually provided, were correctly coded, and were medically necessary. Based on this information, we 
decided that Medicare rules for coverage of procedure code 99232 & 99233 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99232 & 99233 billed for date of service May 
24, 2022 to June 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the positron emission tomography (PET) scan (78815) 
provided on August 31, 2022. 
 
You asked the Plan to pay for the PET scan. You say that this service was billed correctly, and the diagnosis 
code submitted is appropriate. The Plan denied your request. The Plan says this claim was not submitted with 
an appropriate diagnosis code for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that the number of PET scans that are allowed are 
based on the exact diagnosis for which they are provided. As such, Medicare has a list of appropriate diagnosis 
codes that may be used. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PET scan have not been met. Specifically, the diagnosis code reported on this claim is not among those on the list of appropriate diagnosis codes. Therefore, we decided that the Plan does not have to 
pay for the positron emission tomography (PET) scan (78815) provided on August 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 19, 2021, to 
February 1, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records support the billing of principal diagnosis code A41.9-sepsis unspecified organism with DRG 
870. The Plan denied your request. The Plan says the medical records do not support the billing of principal 
diagnosis code A41.9-sepsis unspecified organism with DRG 870. 
 
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 A41.9. 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 medical records do not support the billing of principal diagnosis code A41.9-sepsis unspecified 
organism with DRG 870. Our physician reviewer found the diagnosis of sepsis was not supported by the 
clinical evidence. The enrollee was noted to have a platelet count of 399, a bilirubin of 0.6, and a creatinine of 
1.03. There was no clinical or laboratory evidence of sepsis.  
 
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 on January 19, 2021, to February 1, 2021, at the Diagnosis Related 
Group (DRG) originally billed.