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

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the requested device is medically necessary. The 
Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 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 HFCWOD. Our physician reviewer 
found although request is for diaphragmatic dysfunction, there is no documentation to support this. The 
enrollee is prescribed standard therapy and possibly a vest but does not seem, per documentation, to be 
compliant with vest. There is no indication for HFCWO device at this time per records provided. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power scooter and accessories provided on March 7, 2023. 
 
You asked the Plan to pay for the power scooter and accessories. You say that the power scooter was medically 
necessary. The Plan denied your request. The Plan says the provider is not eligible to receive Medicare 
payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a power scooter and accessories 
provided on March 7, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE), complete, with 
doppler (93306). 
 
You asked the Plan to pre-approve the TTE. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the documentation does not show new or worsening clinical signs or 
symptoms of heart disease. 
 
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 the TTE. Our reviewer says that the 
requested TTE with complete doppler is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation does not point to a change in status that would support 
the medical necessity of a repeat TTE at this time. Clinical guidelines do not support repeating a TTE when the last study in 2021, with no intervening change in clinical status or new signs, symptoms or physical findings. In 
summary, there is no supportive evidence for the medical necessity of repeat TTE in this this patients clinical 
management. Therefore, the reviewer found that the requested TTE with complete doppler is not medically 
reasonable or 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 the TTE have not been met. Therefore, we decided that the Plan does not have 
to pre-approve transthoracic echocardiography (TTE), complete, with doppler (93306).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing provided on January 23, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that the claim was billed 
with a missing or invalid Z-code. 
 
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. The Plan argues that the claim was billed with a missing or invalid Z-code. We 
find that the claim was billed with Z-code Z89G0. The documentation submitted by the Plan shows that this 
code is appropriate for the billed genetic testing. As such, the Plan's denial cannot be substantiated. Therefore, 
we decided that the Plan has to pay for the genetic testing provided on January 23, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced pneumatic compression device. 
 
You asked the Plan to pre-approve the requested device. You say that the device will prevent the condition 
from worsening. The Plan denied your request. The Plan says coverage criteria have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices are only covered 
under certain medical indications.  
 
We looked at the file and Medicare rules. The medical records do not include at least four weeks of regular, 
daily, multiple-hour home usage of an E0650 or E0651 device. Based on this information, we decided that 
Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an advanced pneumatic compression device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair. 
 
You asked the Plan to pre-approve a Group 2 power wheelchair. You say that you are not able to walk. You 
also say that your bottom is raw from scooting around. The Plan denied your request. The Plan says there is no 
documentation showing that your home is suitable for use of the requested device. 
 
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 Group 2 power wheelchair. Our reviewer says that the requested Group 2 power wheelchair is not medically necessary. Our physician reviewer 
found the provided documentation does not indicate a manual wheelchair is insufficient for managing self-care 
in the home. Therefore, the reviewer found that the requested Group 2 power wheelchair is not medically 
reasonable or 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 Group 2 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 2 power wheelchair.
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 the IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for the IRF admission.  
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. The enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that th enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF as medically necessary care 
can be provided in a different level of care.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88305, 88108 and 88311) billed for date 
of service February 28, 2023. 
 
You asked the Plan to pay for pathology services. You say that these services were reported appropriately and 
should be paid. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be 
reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that I31.39 has an Excludes1 note in relation to I30.9. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for pathology services have not been met. Therefore, we decided that the Plan does not have to pay for 
pathology services (88305, 88108 and 88311) billed for date of service February 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve colostomy supplies from an out-of-network (OON) 
provider.  
 
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 available from network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
colostomy supplies from an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (87481, 87491, 87563, 87640, 87653, 
87798, 87641 and 87500) billed for date of service January 10, 2023. 
 
You asked the Plan to pay for the laboratory panel. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says this panel is not supported as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory panel (87481, 87491, 87563, 87640, 87653, 87798, 87641 and 
87500) billed for date of service January 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0856) and accessories 
(E0953, E0955, E1002, E1028, E2300, E2311, E2361, E2605, E2620, K0040). 
 You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested wheelchair 
and accessories are medically necessary for the enrollee's condition. The Plan denied your request. The Plan 
says the enrollee does not have a medical need for a single power option included with group 3 power 
wheelchair. 
 
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 power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has multiple neurological injuries including strokes and 
brachial plexus injury, He remains independent with grooming, bathing, and dressing. Per L33789, the enrollee 
does not have high risk for skin breakdown, use a catheter intermittently, have spasticity or require an 
alternative means of managing power drive. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 power wheelchair (K0856) and accessories (E0953, 
E0955, E1002, E1028, E2300, E2311, E2361, E2605, E2620, K0040).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 78831-26-XU performed on April 3, 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 Current Procedural Terminology (CPT) code 78831-26-XU (1 Unit) remains 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 78831 is "Radiopharmaceutical localization of tumor, 
inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool 
imaging, when performed); tomographic (SPECT), minimum 2 areas (eg, pelvis and knees, chest and 
abdomen) or separate acquisitions (eg, lung ventilation and perfusion), single day imaging, or single area or 
acquisition over 2 or more days" 
 
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 CPT 78831 with modifier XU is 
not supported. The record shows that 78831 is part of the procedure reported with 79445 and should not be 
reported separately. CPT 78831 is not supported as a separate and distinct procedure. 
 
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 78831-26-XU performed on April 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Koya Dayspring Active Compression system 
(K1024, K1032). 
 
You asked the Plan to pre-approve the Koya Dayspring system. You say that you request for overturn and 
approval of the request for the Koya Dayspring Active Compression system as it has been proven effective for 
the enrollee's ongoing manage of their lymphedema. The Plan denied your request. The Plan says this item is 
considered experimental and investigational as medical studies have not proven that this device is helpful for 
the treatment of the enrollee's health problem. 
 
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. The clinical value and effectiveness of non-pneumatic compression 
controller with garment in the setting of lymphedema have not been demonstrated in peer reviewed literature. 
More research is needed to show safety and efficacy of the requested device. Based on this information, we decided that Medicare rules for coverage of the Koya Dayspring system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Koya Dayspring Active Compression system (K1024, 
K1032).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve ablation. 
 
You asked the Plan to pre-approve the genicular nerve ablation. You say that the enrollee had a similar 
procedure on their hip, and it has helped them ambulate. The Plan denied your request. The Plan says the 
genicular nerve ablation is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
  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 genicular nerve ablation have been 
met. Specifically, after multiple attempts, no medical records were received by the Plan. Therefore, we decided 
that the Plan does not have to pre-approve the genicular nerve ablation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0480 billed for date of service July 11, 
2023.  
 
You asked the Plan to pay for procedure code G0480. You say that the coding and diagnosis are approved by 
Medicare. The Plan denied your request. The Plan says payment for code G0480 is bundled into payment for 
code 80307. 
 
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 G0480 is a column two code to column one code 80307 with a modifier indicator of 0. The column two code is 
therefore not payable. 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 G0480 billed for date of service July 11, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide visits. 
 
You asked the Plan to pre-approve the aide services. You say that these services were requested by your doctor 
and are supported by both your PCP and physical therapist. You say that it is taxing for you to leave your 
home. You also say that these services are medically necessary for you. The Plan denied your request. The Plan 
says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found the provided 
records do not indicate that you have documented home health skilled nursing needs, or home health skilled 
therapy needs. The documentation supports that that you are wheelchair-bound. The documentation does not 
support that you are homebound. Therefore, the reviewer found that the requested home health aide visits are 
not medically reasonable or 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 the aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health aide visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rollator walker from an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve these services. You say that the walker is needed to prevent future falls. The 
Plan denied your request. The Plan says the services are available from network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a rollator walker from an out-of-network (OON) provider.