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

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found provided records document that the home 
ventilator is being requested for use in a pressure support mode which is a modality that could be provided by a 
bilevel positive airway pressure (BiPAP) device with average volume assured pressure support (AVAPS) and a 
back-up rate. Provided records do not document trial and failure of a BiPAP device with AVAPS and a back-up 
rate. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64450 billed for date of service March 21, 
2023. 
 
You asked the Plan to pay for procedure code 64450. You say that this was a separate procedure. The Plan 
denied your request. The Plan says payment for code 64450 is bundled into payment for code 01402. 
 
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 64450 is a column II code to column I code 01402. The medical 
records provided do not show that code 64450, billed with the -59 modifier, was a separate and distinct 
procedure. 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 64450 billed for date of service March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sprint peripheral nerve stimulation (PNS) system. 
 
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 services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the Sprint PNS system is experimental 
in nature for shoulder and back pain. The services are not reasonable or medically necessary for the enrollee. 
 
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 a Sprint peripheral nerve stimulation (PNS) system.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an air-fluidized bed. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an air-fluidized bed is covered when specific 
criteria 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the documentation from July 25, 2023 indicates that the enrollee has bilateral ischial pressure ulcers that are stage three and bilateral stage three 
pressure ulcers to the knees. She has a knowledgeable caregiver at home and has failed at least four weeks of 
conservative care. The criteria for coverage are met and the air-fluidized bed is medically necessary at this 
time. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve an air-fluidized bed.  
 
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 physician services provided on March 27, 2023, billed with 
evaluation and management (EM) code 99291. 
 
You asked the Plan to pay for the physician services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the physician services provided have 
been met. Specifically, the medical records do not include the actual date services were rendered. Dictation 
date and time is insufficient to verify the date of service. Therefore, we decided that the Plan does not have to 
pay for physician services provided on March 27, 2023, billed with evaluation and management (EM) code 
99291.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99490 billed for date of service May 24, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the physician provides clinical oversight of the 
nursing team. The Plan denied your request. The Plan says the billed code 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 code 99490 is chronic care management services; first 20 
minutes of clinical staff time directed by a physician or other qualified health care professional. 
 
 We find that CPT code 99490 is not supported in the medical record. Specifically, the documentation does not 
include records for the date of service at issue. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99490 billed for date of service May 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae BRCA1/2 panel and the Common Hereditary 
Cancers Genes Eligible for Ribonucleic acid (RNA) testing provided on March 1, 2023. 
 
You asked the Plan to pay for the Invitae BRCA1/2 panel and the Common Hereditary Cancers Genes Eligible 
for RNA. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
services rendered are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that separate payment for multiple methods to test for 
the same analyte are not covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the Invitae BRCA1/2 Panel are already 
included in the Invitae Common Hereditary Cancer panel + RNA. The Common Hereditary Cancers Genes 
Eligible for RNA Cancers Panel is duplicative and is not expected to give additional information separate from 
the approved test and is unnecessary. Based on this information, we decided that Medicare rules for coverage 
of the Invitae BRCA1/2 panel and the Common Hereditary Cancers Genes Eligible for RNA have not been met. Therefore, we decided that the Plan does not have to pay for the Invitae BRCA1/2 panel and the Common 
Hereditary Cancers Genes Eligible for Ribonucleic acid (RNA) testing provided on March 1, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0300, Q5001, G0299) provided on 
April 14, 2022, to May 13, 2022. 
 You asked the Plan to pay for home health services. You say that the claim denied in error. You are requesting 
reconsideration. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 15, 2022. The NOA was not received by the Plan until June 9, 2022. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services (G0300, Q5001, 
G0299) provided on April 14, 2022, to May 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 21, 2023. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says this claim was submitted with two 
incompatible diagnosis codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that when a diagnosis code has an Excludes1 note, it is inappropriate to report the noted condition 
together with the condition with the note.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, this claim was submitted with diagnosis codes 
G89.29 (other chronic pain) and R52 (pain, unspecified). However, codes within the G89 code group have an 
Excludes1 note with code R52. Code R52 likewise has an Excludes1 note with G89 codes. This means it is 
generally inappropriate to report these diagnoses together. Therefore, we decided that the Plan does not have to 
pay for laboratory services provided on February 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83520 billed for date of service April 15, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the specimens are received from providers. The 
Plan denied your request. The Plan says the billed code 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 code 83520 is immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. We find that CPT code 83520 
is not supported in the medical record. The records do not show that the billed service was provided. Based on 
this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 83520 billed for date of service 
April 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee walker (E0118). 
 
You asked the Plan to pre-approve a knee walker. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 knee walker. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is a lack of medical literature indicating that a knee walker is safer and/or more effective 
in terms of improving mobility than crutches or a manual wheelchair. Therefore, the knee walker 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 knee walker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee walker (E0118).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies billed for date of service March 8, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the dressings are a covered benefit. The Plan 
denied your request. The Plan says the date of service billed is not appropriate. 
 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 looked at the file and the rules. The claim information shows that the enrollee was receiving inpatient care 
from March 5, 2023, to March 14, 2023. The rules for the date of service billed for the supplies at issue have 
not been met. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for the wound care supplies billed 
for date of service March 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a scooter (K0800). 
 
You asked the Plan to pre-approve a scooter. You say that the power scooter has been medically necessary for 
over 15 years. You also say that you cannot go to the kitchen and cook due to not being able to stand or walk 
for long periods of time. The Plan denied your request. The Plan says you do not meet the criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a scooter. Our reviewer says that the 
power scooter is not medically necessary. Our physician reviewer found you are noted to have difficulty 
ambulating and pain. However, you are also noted to be able to use a walker or manual wheelchair for mobility 
in your home and have sufficient strength to accomplish this. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a scooter (K0800).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 6, 2023, to 
March 3, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that a NOA is only required for the 
patient's initial visit, and you provided a copy of the NOA. 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 6, 2023, to 
March 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Relese skin substitute. 
 
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 services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has basal cell carcinoma of 
the skin of the left ear and external auricular canal and is scheduled for a Mohs procedure. The records do not 
document failure of standard wound treatment for at least a 30-day period during organized comprehensive 
conservative therapy. The criteria for coverage are not met and the services are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Relese skin substitute.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 70491, 71275, and 74175 for date of service 
April 10, 2023. 
 
You asked the Plan to pay for procedure codes 70491, 71275, and 74175. 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 codes 70491, 71275, and 74175 are not payable as billed. Specifically, codes 71275 and 
74175 have a status indicator of Q3. These services were billed on the same date of service as code 70491. 
Codes 71275 and 74175 are not separately payable when billed with code 70491. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 71275 and 74175 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 70491, 71275, and 74175 for date of service 
April 10, 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 
March 6, 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 March 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital stay following a left reverse 
shoulder arthroplasty and bicep tenodesis. 
 
You asked the Plan to pre-approve an inpatient hospital stay. You say that the procedure is medically 
necessary. The Plan denied your request. The Plan says there is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 inpatient hospital stay. Our reviewer 
says that the documentation does not support that the criteria for an inpatient stay are met in this case. Our 
physician reviewer found the record provided does not indicate that the treating physician has a reasonable 
expectation of a length of stay spanning 2 or more midnights, taking into account complex medical factors. The 
initial day may be spent in observation until it is clearly expected that a second midnight would be required, at 
which time the physician may order inpatient admission. Our reviewer found that the elements of the coverage 
criteria are not satisfied. Our physician reviewer also found that the requested service is not 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 an inpatient hospital stay have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an inpatient hospital stay following a left reverse shoulder arthroplasty and 
bicep tenodesis.