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

 
We decided that the Plan does not have to pre-approve a PureWick System Starter Set with Battery and 
Subsequent Supplies. 
 
You asked the Plan to pre-approve a PureWick System Starter Set with Battery and Subsequent Supplies. You 
say that the items are medically necessary. The Plan denied your request. The Plan says theres no 
documentation that the enrollee has permanent incontinence or retention. 
 
The Plan must follow Medicare rules. Medicare rules say that urinary catheters and external urinary collection 
devices are covered to drain or collect urine for a beneficiary who has permanent urinary incontinence or 
permanent urinary retention. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a PureWick System Starter Set with Battery and Subsequent Supplies have not been met. 
Specifically, theres no documentation that the enrollee has permanent incontinence or retention. Therefore, we 
decided that the Plan does not have to pre-approve a PureWick System Starter Set with Battery and Subsequent 
Supplies.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Metaxalone. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee had reaction to a medication. You 
also say that you would like the enrollee to continue this medication. The Plan denied your request. The Plan 
says the medication is not covered as a medical benefit under the 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 Metaxalone.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says the required services can be provided in an alternate 
setting.  
 
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 the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are not getting the appropriate amount of 
therapy. The Plan denied your request. The Plan says we are unable to approve the request for coverage.  
 
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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your rehabilitation needs 
can be safely provided in an alternate and low intensity setting such as in a skilled nursing facility.  
 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88334 and 88341 billed for date of service 
May 5, 2023. 
 
You asked the Plan to pay for the billed services. You say that the services should not be bundled with any 
other service. The Plan denied your request. The Plan says the billed services are not payable. 
 
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. We looked at the file and Medicare rules. The file 
shows that 4 units of code 88341 was reimbursed by the Plan on July 7, 2023. A comparison of the claims 
shows these are exact duplicates. There is no evidence presented to support that the billed services were 
provided twice on the same date. Based on this information, we decided that the Medicare rules for coverage 
have not been met. 
 
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 88334 is 5. The MAI value for this code is 3. You billed 6 units of this code, exceeding the MUE. The 
documentation does not show that excess units were required for the treatment of this specific enrollee. Based 
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 88334 and 88341 billed for date of service May 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
June 19, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
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 code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service June 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure 
(CPAP) face mask and supplies on December 9, 2022, to April 25, 2023. 
 
You asked the Plan to waive the coinsurance for the CPAP face mask and supplies. You say that you have 
never had to pay the bill that was that high before and you dont agree with the charges. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance of the total cost for Medicare-covered durable medical equipment.   
 
You have been asked to pay a 20% coinsurance for each CPAP face mask and supplies. This item/service falls 
within the durable medical equipment (DME) and related supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. The total amount you owe is $139.93, which is 
20% coinsurance of the allowed amount for each item. Therefore, we decided that the Plan does not have to 
waive the coinsurance for the continuous positive airway pressure (CPAP) face mask and supplies on 
December 9, 2022, to April 25, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on May 24, 2023. 
 You asked the Plan to pay for the medical services. You say that this claim is payable even though you are out-
of-network with the Plan. The Plan denied your request. The Plan says the diagnosis code at issue is not 
appropriate as a primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code J12.82. This code 
is not an appropriate primary diagnosis as the code has a Code first note indicating to code the underlying 
condition first. Based on this information, we decided that Medicare rules for payment of this claim have not 
been met. Therefore, we decided that the Plan does not have to pay for medical services provided on May 24, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the enrollee says that their back pain is 
causing severe problems. The Plan denied your request. The Plan says this procedure is considered 
investigational.  
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental and more research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 19, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the OON laboratory services. You say that you were not aware of the enrollee's 
insurance prior to receiving the specimen and were unable to determine the enrollee's status. The Plan denied 
your request. The Plan says the OON services in dispute were not urgent or emergent and were not pre-
authorized. 
 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 services at issue in this appeal. The Plan did not pre-approve the OON 
service at issue. We found that the referring provider who sent the specimen to your facility was also non-
contracted with the Plan. We found no exception that would require the Plan to pay for these OON services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on May 19, 2023, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the interrogation device evaluation 
(remote) provided on June 20, 2023. 
 
You asked the Plan to waive the copayment for the interrogation device evaluation (remote). You say that you 
had the same service done before with no copaymet so therefore there should not be a copayment for the same 
thing when it was done remotely. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $20 copayment for the interrogation device evaluation (remote). This item/service falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the interrogation device evaluation (remote) provided on 
June 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a floor standing lift aide (E1399) provided on April 6, 2023. 
 
You asked the Plan to pay for the aide. You say that this is medically necessary. The Plan denied your request. 
The Plan says this does not meet the requirements for approval. 
 
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 aide. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support that the enrollee requires a mechanical lift for transfer, or that 
the enrollee would be bed bound with the lift. 
 
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 aide have not been met. Therefore, we decided that the Plan does not have 
to pay for a floor standing lift aide (E1399) provided on April 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 15, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on July 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options and accessories. 
 
You asked the Plan to pre-approve the group 3 power wheelchair with multiple power options and accessories. 
You say that this wheelchair is medically necessary. The Plan denied your request. The Plan says a more 
simple power wheelchair can meet the enrollee's needs. 
 The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with multiple power 
options is covered when the enrollee meets coverage criteria for a group 3 power wheelchair AND they require 
power tilt & recline or have a ventilator attached to the wheelchair. 
 
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 group 3 power wheelchair with 
multiple power options and accessories. Our reviewer says that this type of wheelchair is not medically 
necessary. Our physician reviewer found there is insufficient documentation regarding the patients level of 
function in terms of performing daily activities. The patient does have multiple sclerosis, but group 3 power 
wheelchairs are required for patients with more significant paralysis, complex seating requirements, and an 
inability to perform pressure relief. Since the base wheelchair does not meet coverage criteria, the requested 
accessories are non-covered. 
 
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 group 3 power wheelchair with multiple power options and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair 
with multiple power options and accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code U0004 billed for July 5, 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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rule say that CLIA-waived tests are billed with the -QW modifier. 
 
We looked at the file and Medicare rules. The file shows that code U0004 was billed with the -QW modifier to 
indicate it is waived due to CLIA; however, this test is not listed as waived in the CLIA List and the modifier is not appropriate. Therefore, we decided that the Plan does not have to pay for procedure code U0004 billed for 
July 5, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the radiologic examination (x-ray) of the knee (73564) provided on 
February 10, 2023. 
 
You asked the Plan to pay for the x-ray. You say that medical records support code 73564 and should be paid. 
The Plan denied your request. The Plan says that code 73564 was denied for not having an anatomical 
modifier. The Plan says that this edit will deny claims when an anatomical modifier was not appended to 
specific codes.  
 
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. We find that that the Plans cited rule has been misinterpreted in this case. While 
the rule does state that anatomical modifiers are to be used when appropriate, this rule appears in a section that 
related to National Correct Coding Initiative (NCCI) edits. There is no NCCI edit at issue in this case. The 
billed code is for an x-ray examination of one knee, and the record shows that this service was performed. We 
find no other basis to deny payment for this service. Therefore, we decided that the Plan has to pay for the 
radiologic examination (x-ray) of the knee (73564) provided on February 10, 2023.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 11, 2023, to 
May 17, 2023, 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 
codes and diagnoses reported on this claim are appropriate and supported as billed. The Plan denied your 
request. The Plan says diagnosis code G93.41 is not supported, which resulted in a DRG change. 
 
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 G93.41 - metabolic encephalopathy. 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 physician reviewer found the documentation describes the enrollee as oriented x3 in one place but noted to 
have baseline mental status with confusion as to the enrollee's place and year. It appears that there was no 
clearly and consistently documented acute metabolic encephalopathy beyond the enrollee's baseline mental 
status related to their dementia to support the secondary diagnosis code G93.41 (metabolic encephalopathy) 
and originally billed DRG 871 for this admission.   
 
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 May 11, 2023, to May 17, 2023, at the Diagnosis Related Group 
(DRG) originally billed.
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 August 28, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says this is a non-covered service. 
 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 August 28, 2023.