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

 
We decided that the Plan does not have to pay for the infusion supplies not for use with an infusion pump 
provided from April 28, 2022, to May 5, 2022, billed with code A4223. 
 
You asked the Plan to pay for the infusion supplies. You say that you feel that this should be covered as the 
treatment is medically necessary. The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that drugs and supplies for home infusion are only 
covered when used with a covered infusion pump. Code A4223 is for infusion supplies used without a pump 
and cannot be covered. Therefore, we decided that the Plan does not have to pay for the infusion supplies not 
for use with an infusion pump provided from April 28, 2022, to May 5, 2022, billed with code A4223.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 11, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the denial 
and have submitted medical records for review. The Plan denied your request. The Plan says Medicare does not 
separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 11, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery to be provided by an out-of-network (OON) 
provider at the in-network coverage level. 
 
You asked the Plan to pre-approve surgery. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested services can be provided by a network provider. 
 
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. We note that the enrollee may receive these services from an 
OON provider; however, their cost share requirement will be higher. Therefore, we decided that the Plan does 
not have to pre-approve surgery to be provided by an out-of-network (OON) provider at the in-network 
coverage level.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute, lower leg platform, with or without 
wheels (E0118). 
 
You asked the Plan to pre-approve a knee scooter. You say that you had retrocalcaneal surgery and you cannot 
walk or put any pressure on your foot at all. You need this knee scooter to get around. The Plan denied your 
request. The Plan says the requested knee scooter does not primarily serve a medical purpose and is not 
reasonable and necessary to treat an illness or injury this is not covered under any condition. 
 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 a crutch substitute, lower leg platform, with or without 
wheels (E0118).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99053 and 99284 billed for date of service 
June 16, 2022. 
 
You asked the Plan to pay for procedure codes 99053 and 99284. You say that your organization provided 
medically necessary services and this claim should be paid. The Plan denied your request. The Plan says 
procedure code 99053 is considered bundled and not separately payable. The Plan also says that payment for 
code 99284 is bundled into payment for code 99285 billed on the same date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. In this case, we have confirmed that code 
99284 is a column II code to column I code 99285. 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. 
 
We also find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means 
that procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules 
for coverage of procedure codes 99053 and 99284 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 99053  and 99284 billed for date of service June 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (three or four wheel, 
nonhighway) (E1230). 
 
You asked the Plan to pre-approve a power scooter. You say that you have hip pain and was informed that you 
need a hip operation. You have an office chair to move around and do not have the strength to push a 
wheelchair. The Plan denied your request. The Plan says this request is not medically necessary as the enrollee 
is able to ambulate with a single point cane within the home and no home evaluation has been done for medical 
necessity and home accessibility of a PMD. 
 
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.  
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power operated vehicle (three or four wheel, nonhighway) (E1230).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 2, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, we find that the testing described by the billed code 
is considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on August 2, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for vascular imaging services (procedure codes 75726 and 75774) provided 
ot the enrollee on June 9, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the denied codes cannot be verified. 
 
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, the CPT Code Manual definition of 
the denied codes is: 
 
CPT 75726: 
 
Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision 
and interpretation 
 
CPT 75774: 
 
Angiography, selective, each additional vessel studied after basic examination, radiological supervision and 
interpretation (List separately in addition to code for primary procedure) 
 
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 the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the documentation supports coverage 
of the codes in question. Diagnostic angiography in preparation for embolization is separately billable and not 
bundled with the code for embolization. CPT 75726 codes for visceral angiogram; there is satisfactory 
documentation of angiography of the celiac artery and its branches. CPT 75774 codes for additional 
angiography of vasculature that required separate placement of the catheter. This is also satisfactorily 
documented where catheterization of the proximal gastroduodenal artery and subsequent angiography is 
performed. 
 
We looked at this coder'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 pay for 
vascular imaging services (procedure codes 75726 and 75774) provided ot the enrollee on June 9, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99308 & 99309 billed for date of service 
November 13, 2021 to December 4, 2021. 
 
You asked the Plan to pay for procedure codes 99308 & 99309. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. The codes billed have a bundled relationship and cannot be paid together. 
 
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. Rules also state that some code pairs should 
not be reported together. 
 
In this case, the MUE for CPT code 99309 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Code 99308 has a bundled relationship with code 99309 and was not billed with a 
modifier. Based on this information, we decided that Medicare rules for coverage of procedure codes 99308 & 
99309 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 99308 
& 99309 billed for date of service November 13, 2021 to December 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair (K0003). 
 
You asked the Plan to pre-approve a lightweight wheelchair. You say that you are not supposed to walk at all 
unless absolutely necessary. Your stem of your implant is broken in half and could come through your thigh if 
walked on too much. You are awaiting a date for surgery but in the meantime, you need the requested 
wheelchair. You have attached your x-ray showing why you need this wheelchair. The Plan denied your 
request. The Plan says you do not have documentation that your mobility limitation cannot be sufficiently 
resolved using an appropriately fitted cane or walker. The order submitted by your physician office calls for a 
standard wheelchair. You are insisting on a lightweight 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.  
 
The file shows that your physician requested a standard wheelchair. The records show you do not have a 
mobility deficit that impairs your participation in MRADLs. You do not meet the coverage criteria for the 
purchase of the lightweight wheelchair. In addition, the requested DME supplier has reported that they have not 
received any orders from your provider for this wheelchair. This means that Medicare rules for coverage of a 
PWC have not been met. Therefore, we decided that the Plan does not have to pre-approve a lightweight 
wheelchair (K0003).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FitSpine x3 Inversion table (E1399) and sales tax 
(S9999) purchased July 22, 2022. 
 
You asked the Plan to pay for the inversion table. You say that you checked 10 in-network providers to order 
an inversion table that was prescribed by your doctor. Since this was prescribed by your doctor, Medicare 
covers inversion tables as durable medical equipment. The Plan denied your request. The Plan says This item is 
considered a convenience item, is not primarily medical in nature and is not covered by Medicare 
 
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 pay for the FitSpine x3 Inversion table (E1399) and sales tax (S9999) 
purchased July 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator, with integrated 
electrocardiogram analysis, garment type (K0606) provided on June 12, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the automatic external defibrillator. You say that the medical records provided 
will show proof of medical necessity. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the automatic external defibrillator, with 
integrated electrocardiogram analysis, garment type (K0606) provided on June 12, 2022, by an out-of-network 
(OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from March 
17, 2022, to April 12, 2022. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was not reported correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that the home health services are not supported in the medical record. Specifically, this was not 
reported with an appropriate type of bill. 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 pay for home 
health services provided to the enrollee from March 17, 2022, to April 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 1, 2022, billed with 
codes 81162, 81292, 81295, 81298, 81317, 81321, 81351, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 1, 2022, billed with codes 81162, 81292, 81295, 81298, 81317, 81321, 81351, and 81479.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 24, 2022 to 
July 23, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this should be paid for. The Plan 
denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 24, 2022 to July 23, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 14, 2022 to 
March 15, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this should be paid for. The Plan 
denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 14, 2022 to 
March 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Verio test strips (A4253). 
 
You asked the Plan to pre-approve the diabetic supplies. You say that the enrollee uses OneTouch Verio as it is 
compatible with their current glucometer. The Plan denied your request. The Plan says the requested item is not 
a Plan preferred product and is not covered by the Plan. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. In this case the enrollee has not tried and failed a Plan preferred 
diabetic product and does not meet the criteria for approval of a non-preferred product. Based on this 
information, we decided that Medicare rules for coverage of the diabetic supplies have not been met. Therefore, 
we decided that the Plan does not have to pre-approve OneTouch Verio test strips (A4253).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on April 28, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the denial. 
The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on April 
28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services at the LTACH that you require that are not already available and 
covered at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.