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

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on May 25, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on May 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary immediate denture (D5130), removal of torus 
palatinus (D7472 x 2) and extractions provided on June 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told everything would be covered and 
that you would not have gotten the new denture otherwise. The Plan denied your request. The Plan says these 
services are not covered benefits under your dental plan, or the procedure code submitted may be more 
accurately represented by another code. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.   
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 dental services. Our reviewer says that 
the extractions were appropriately downgraded. Our physician reviewer found that the clinical notes the 
provider submitted did not note whether bone was removed around the teeth, nor was there documentation 
regarding any sectioning of the teeth in order to remove them. Additionally, though the Plan offers a dental 
benefit in excess of Medicare coverage D5130 and D7472 are not among those covered under this benefit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pay for the maxillary immediate denture (D5130), removal of torus palatinus (D7472 x 2) and 
extractions provided on June 26, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 73660-TA billed for date of service July 23, 2023. 
 
You asked the Plan to pay for code 73660-TA. You say that this is a payable code. The Plan denied your 
request. The Plan says this code is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that STV-packaged services are services for which separate 
payment is made only if there is no service with status indicator S, T, or V reported on the same claim. If a 
claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged 
services are assigned status indicator Q1. In this case, the code in dispute has a status indicator of QI, meaning 
that it is a STV-packaged service.  This disputed code was billed on the same claim with a code that has a status indicator of S, T, or V.  This means that the code in dispute in this appeal is not separately payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 73660-TA have not been met. Therefore, we decided that the Plan does not have to pay for 
code 73660-TA billed for date of service July 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95004, 95024, 3077F, 3078F, 1159F, and 
1160F billed for date of service July 20, 2023. 
 
You asked the Plan to pay for the billed services. You say that the codes are all correct. The Plan denied your 
request. The Plan says the billed codes are 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 95004 is percutaneous tests (scratch, puncture, prick) 
with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of 
tests. The definition of code 95024 is intracutaneous (intradermal) tests with allergenic extracts, immediate 
type reaction, including test interpretation and report, specify number of tests. We find that CPT codes 95004 
and 95024 are not supported in the medical record. Specifically, the records do not show these tests were 
provided. The records do not include an interpretation and report for these tests.  
 
We find that procedure codes 3077F, 3078F, 1159F, and 1160F have a Status Indicator of I on the Physician 
Fee Schedule. This means that these codes are not valid for Medicare purposes. 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 95004, 95024, 3077F, 3078F, 1159F, and 1160F billed for date of service July 20, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 2, 2023, to April 
8, 2023. 
 
You asked the Plan to pay for the home health services. You say that you are resubmitting this appeal request. 
The Plan denied your request. The Plan says you billed the claim for these services with an incorrect Type of 
Bill code. 
 
The Plan must follow Medicare rules. The rules state that the Type of Bill code is a 4-digit alphanumeric code 
that gives two pieces of information. The first three digits indicate the base type of bill. The fourth digit 
indicates the sequence of this bill in this particular period of care. The acceptable 4th digit options are as 
follows: 7 (to indicate a replacement of a prior claim); 8 (to indicate a void or cancel of a prior claim); and 9 (a 
final claim).   
Based on these rules, the final claim for the home health services in dispute should have been billed with Type 
of Bill code 329.  However, you billed code 323. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided from April 2, 2023, to April 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 12, 2023. 
 
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 testing was not billed correctly. 
 
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 services rendered on June 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, 87798, 87651, 87556, 87561, 
87641, 87640, and 87551 billed for date of service February 28, 2023.  
You asked the Plan to pay for procedure codes 87481, 87653, 87798, 87651, 87556, 87561, 87641, 87640, and 
87551.  The Plan denied your request. The Plan says payment for codes 87481, 87653, 87798, 87651, 87556, 
87561, 87641, 87640, and 87551 is bundled into payment for code 87801. 
 
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 codes 
87481, 87653, 87798, 87651, 87556, 87561, 87641, 87640, and 87551 are column II codes to column I code 
87801. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes 87481, 87653, 87798, 87651, 87556, 87561, 87641, 87640, and 87551 billed for date 
of service February 28, 2023.
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 Home Healthcare services the enrollee is getting 
right now verifies their ability to withstand 3 hours of therapy. You also say that the enrollee needs more 
aggressive therapy as they have previously been to a skilled nursing facility and it has not helped them get 
better. The Plan denied your request. The Plan says the enrollee does not require oversight of a physical 
medicine and rehabilitation physician.  
 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 enrollee is medically stable with no acuity and does not need a physical medicine 
and rehabilitation physician's supervision 3 times a week in an IRF. No acute rehabilitation skilled nursing 
needs identified or documented. Our reviewer found that the enrollee needs physical therapy and occupational 
therapy, and does not need specialized intensive therapies consisting of at least 3 hours of therapy per day at 
least 5 days per week with multidisciplinary approach in an IRF. The documentation does not support necessity 
for admission to an IRF. With no medical complexity, and no rehabilitative nursing needs as described above 
the enrollee does not require an IRF stay. Our physician reviewer also found that the enrollee's rehabilitation 
needs can be provided in an alternate and low intensity setting such as in an SNF or continued services at 
home.  
 
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 the laboratory services rendered on August 25, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
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 services rendered on August 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Truxima. 
 
You asked the Plan to pre-approve Truxima. 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 Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 Truxima. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the review has determined that the 
documentation does not support that the Truxima is medically reasonable and necessary or safe and effective 
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 Truxima have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Truxima.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Pride Jazzy Carbon Lightweight power operated 
vehicle (POV) (K0899). 
 
You asked the Plan to pre-approve a Pride Jazzy Carbon Lightweight POV. You say that you are requesting 
this as a medical necessity as it will benefit your patient based on their medical conditions and/or diagnosis. 
The Plan denied your request. The Plan says the requested model POV is not covered/not medically necessary. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that POVs and PWCs which have not been reviewed by the 
PDAC will be denied as not reasonable and necessary and should be coded as K0899. 
 
We find that the type of scooter you purchased has not been reviewed by the PDAC and carries the Healthcare 
Common Procedure Coding System (HCPCS) code of K0899. This means that the scooter in dispute is not 
considered reasonable and necessary. Based on this information, we decided that Medicare rules for coverage 
of a Pride Jazzy Carbon Lightweight POV have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Pride Jazzy Carbon Lightweight power operated vehicle (POV) (K0899).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the foot insert (L3000). 
 
You asked the Plan to pre-approve the foot insert. You say that the services requested are medically necessary. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve the foot insert (L3000).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nutritional supplies (B4197, B4224, B4220) provided on July 
14, 2023 to July 19, 2023. 
 
You asked the Plan to pay for the nutritional supplies. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid proof of delivery for the supplies provided in this case. No itemized patient 
receipt or proof of delivery was provided. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for 
nutritional supplies (B4197, B4224, B4220) provided on July 14, 2023 to July 19, 2023.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve $9,868.25 in PWC repairs. We decided that the Plan does not have 
to pre-approve an additional $4,205.50 in PWC repairs.  
 
You asked the Plan to pre-approve repairs for a power wheelchair (PWC) in the amount of $14,073.75. You 
say that the repairs are medically necessary. The Plan says that when the expense for repairs exceeds the 
estimated expense for replacement of the wheelchair, they are not covered. 
 
We decided that the Plan has to pre-approve $9,868.25 in PWC repairs.  
 
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 file shows that the original purchase price of the power wheelchair (PWC) 
was $18,648.65. The file shows that $8,780.40 has been paid for previous repairs. $18,647.65 - $8,780.40 = 
$9,868.25. Therefore, we decided that the Plan has to pre-approve $9,868.25 in PWC repairs.  
 
We also decided that the Plan does not have to pre-approve an additional $4,205.50 in PWC repairs. 
 
The Plan must follow Medicare rules. The rules say that if the expense for repairs exceeds the estimated 
expense of purchasing or renting another item of equipment for the remaining period of medical need, no 
payment can be made for the amount of the excess. 
 
The file shows that with the approval of $9,868.25 towards the requested PWC repairs in dispute and the 
$8,780.40 in previous repairs, the total remaining $4,205.50 in repairs would exceed the cost of the original 
purchase price. Therefore, we decided that the Plan does not have to pre-approve an additional $4,205.50 in 
PWC repairs. 
 
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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you feel like inpatient rehabilitation is the best level 
of care for the enrollee. You also say that the enrollee has been in the hospital and needs to have consistent 
rehabilitation in order to have a safe discharge back home. The Plan denied your request. The Plan says based 
on Medicare guidelines, the request for IRF services does not meet the requirements for approval.  
 
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 you do not need a physical medicine and rehabilitation physicians supervision 3 
times a week in an IRF. There are no acute rehabilitation nursing needs documented. Our reviewer found that 
at the current functional level, you need physical therapy and occupational therapy. It is not appropriate for you 
to require intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach in an IRF. The documentation does not support necessity for admission to an IRF. 
The complexity of your medical, rehabilitation, and nursing needs (combined complexity) does not require 
acute hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. Our 
physician reviewer also found that your rehabilitation needs can be safely provided in an alternate and low 
intensity setting such as in a skilled nursing facility when medically stable.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the denial. 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 Dupixent.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.