Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H0038 billed for date of service May 5, 
2023. 
 
You asked the Plan to pay for procedure code H0038. You say that these services were provided in good faith 
and reimbursement would be appreciated. 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 H0038 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code H0038 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code H0038 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code H0038 billed for date of service May 5, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 for date of service February 23, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable 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 99285 is not payable as billed. Specifically, this code was billed with diagnosis codes 
R10.30, R06.00, R10.11, and N39.0. The laterality for one or more of the submitted diagnosis codes does not 
indicate left, right, or bilateral. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99285 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99285 for date of service February 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gauze (A6402). 
 
You asked the Plan to pre-approve gauze. You say that the item is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of a continent stoma. 
 
The Plan must follow Medicare rules. Medicare rules say that beneficiaries with continent stomas may use the 
following means to prevent/manage drainage: stoma cap (A5055), stoma plug (A5081), stoma absorptive cover 
(A5083) or gauze pads (A6216). No more than one of these types of supply would be reasonable and necessary 
on a given day.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of gauze have not been met. Specifically, you do not have a continent stoma and the type of gauze 
requested is not covered as an ostomy supply. Therefore, we decided that the Plan does not have to pre-approve 
gauze (A6402).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty, extra wide hospital bed with weight 
capacity greater than 350 pounds, but less than or equal to 600 pounds (E0303) heavy-duty trapeze equipment 
(E0912) gel pressure pad for mattress, standard mattress length and width (E0185).  
 
You asked the Plan to pre-approve a heavy-duty hospital bed with trapeze bar and gel pressure mattress . You 
say that you are appealing the medical necessity denial for a heavy-duty hospital bed with trapeze bar and gel 
pressure mattress because of gastro-esophageal reflux disease without esophagitis  The Plan denied your 
request. The Plan says the requested hospital bed and accessories were considered not medically necessary  
 
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 heavy-duty hospital bed with trapeze 
bar and gel pressure mattress. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have difficulty 
with mobility due to low back pain and lumbar spine stenosis and radiculopathy. The enrollee also experiences 
more reflux due to Gastroesophageal reflux disease (GERD) when lying flat. A semi electric hospital bed is 
required for patients that require frequent re-positioning while in bed. The enrollee has impaired mobility and 
ability to transfer to and from a bed, but there is no indication that the enrollee cannot achieve repositioning 
while in bed and has not history of skin breakdown. The enrollee is also noted to be 318 pounds and a heavy-
duty hospital bed is indicated in patients weighting more than 350 lbs. The enrollee may benefit from a 
standard hospital bed, but a semi-electric hospital bed is not medically necessary. Therefore, the semi-electric 
heavy duty hospital bed with mattress (E0303), heavy duty trapeze equipment (E0911, E0912) and gel-like 
pressure pad for mattress (E0185) is not 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 a heavy-duty hospital bed with trapeze bar and gel pressure mattress have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty, extra wide hospital 
bed with weight capacity greater than 350 pounds, but less than or equal to 600 pounds (E0303) heavy-duty 
trapeze equipment (E0912) gel pressure pad for mattress, standard mattress length and width (E0185).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ground mileage (A0425) and Ambulance service, basic life 
support (bls), non-emergency transport, (A0428) provided on April 3, 2023. 
 
You asked the Plan to pay for ground mileage (A0425) and Ambulance service, basic life support (bls), non-
emergency transport, (A0428). You say that appealing with supporting records. The Plan denied your request. 
The Plan says this was denied because the details they received from the provider does not meet Medicare 
guidelines that show a medical reason the enrollee needs round trip non-emergency ambulance transportation 
and ground mileage.  
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ground mileage (A0425) and Ambulance 
service, basic life support (bls), non-emergency transport, (A0428). Our reviewer says that the service is not 
medically necessary. Our physician reviewer found the enrollee was not bedbound, as evidenced by her  ability 
to stand-pivot-transfer, sit in a wheelchair and sit in a dialysis chair. Our physician reviewer also found that the 
transportation could have been provided by other means without endangering the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ground mileage (A0425) and Ambulance service, basic life support (bls), non-
emergency transport, (A0428) have not been met. Therefore, we decided that the Plan does not have to pay for 
ground mileage (A0425) and Ambulance service, basic life support (bls), non-emergency transport, (A0428) 
provided on April 3, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve repairs to a power wheelchair. 
 
You asked the Plan to pre-approve repairs. You say that you are appealing this denial. The Plan denied your 
request. The Plan says that the estimated cost of repairs exceeds the expense of replacement; therefore, repairs 
are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that repairs to durable medical equipment (DME) 
may be covered if the cost of repair does not exceed the cost of replacement.  
 
We looked at the file and Medicare rules. The estimated cost of repairs is $186.55. The Plan has indicated that 
no previous repair expenses have been incurred on this equipment. The Plan has indicated that the estimated 
cost of a replacement is $15,932.99. Therefore, the Plans denial on the basis that the cost of repairs exceeds 
the cost of replacement is not supported. Based on this information, we decided that Medicare rules for 
coverage of repairs have been met. Therefore, we decided that the Plan has to pre-approve repairs to a power 
wheelchair.  
 
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 45380 billed for date of service June 9, 2023. 
 
You asked the Plan to pay for procedure code 45380. The Plan denied your request. The Plan says payment for 
code 45380 is bundled into payment for code 45385.  
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 45380 
is a column II code to column I code 45385. 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 45380 billed for date of 
service June 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 rendered on March 6, 2023. 
 
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 the records do not support the services 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, the CPT Code Manual definition of code 99233 is "Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded." 
 
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 not supported by the medical records. Our reviewer found that the documentation does not 
support this level of complexity either by medical decision making or by time. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99233 rendered on March 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 2, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were not billed correctly. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee orthosis (L1852) and suspension sleeve (L2397) 
provided June 26, 2023. 
 
You asked the Plan to pay for the orthosis. You say that you have attached the supporting documentation, 
please reprocess the claim. The Plan denied your request. The Plan says under Medicare, the request is not 
medically necessary. 
 
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 the orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee reported right knee pain (chronic) related to osteoarthritis. A request for a knee 
orthosis with suspension sleeve was made. However, physical examination from October 27, 2022, revealed no 
instability of the knee, recent injury or surgery, or plans for such, or other diagnosis warranting knee bracing. 
Therefore, the LCD criteria was not met for this knee brace and sleeve.  
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for knee orthosis (L1852) and suspension sleeve (L2397) provided June 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint fusion procedure with the NuTech 
Spine SI Fix device (27279). 
 
You asked the Plan to pre-approve SI joint fusion procedure with the NuTech Spine SI Fix device. You say that 
this service is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for coverage of this service. 
 
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 SI joint fusion procedure with the 
NuTech Spine SI Fix device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no sacroiliac instability, fracture, 
or lesion documented in this case. In addition, SI joint fusion for degenerative back pain is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint fusion procedure with the NuTech Spine SI Fix device have not been 
met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac (SI) joint fusion procedure 
with the NuTech Spine SI Fix device (27279).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner lift chair. 
 
You asked the Plan to pre-approve a recliner lift chair. You say that you need it to be able to stand so you can 
walk.  The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
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 recliner lift chair. Our reviewer says 
that the documentation does not support that the requested item is medically reasonable or necessary. Our physician reviewer found the documentation shows that you require a wheelchair for mobility. There is limited 
clinical documentation and history regarding your level of mobility and ability to transfer. You are noted to 
require a manual wheelchair for mobility and to require a power seat lift chair, enrollees must be able to 
ambulate but have difficulty performing transfers. Therefore, you do not meet criteria for the requested item. 
 
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 recliner lift chair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a recliner lift chair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0483) provided on June 21, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 code G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed". 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records provided do not 
show that 22 or more drug classes were tested on the date in question. 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 the drug testing services (G0483) provided on June 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the documentation does not support that the requested item is medically reasonable or 
necessary. Our physician reviewer found the enrollee was admitted to acute inpatient rehabilitation on 
September 1, 2023, after suffering a stroke with left sided hemiparesis. The enrollee was also noted to have 
critical illness myopathy. The enrollee was noted to require moderate to maximum assistance with daily 
activities and moderate assistance with mobility with the use of walker. The enrollee is noted to have three out 
of five motor strength in the left upper extremity and four out of five motor strength in the right upper 
extremity and lower extremities. The enrollee requires moderate assistance with bed mobility and transfers. 
There is insufficient clinical documentation indicating that the enrollee's mobility is not limited such that 
functional position changes cannot be accomplished and that he requires frequent and immediate changes in 
body position. Therefore, the enrollee does not meet criteria for the requested item. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ventilator provided on July 3, 2023, by an out-of-network 
(OON) provider.  
 
You asked the Plan to pay for the ventilator. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the item rendered is not a covered benefit when provided by an OON 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 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 ventilator provided on July 3, 2023, by an out-
of-network (OON) provider.