Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation services (A0428, A0425) provided 
on August 8, 2022. 
 
You asked the Plan to pay for ambulance transport. You say that these services were necessary and are 
supported in the medical records. The Plan denied your request. The Plan says the payment for this service 
would be included in the payment to the facility where the enrollee maintained inpatient status on the date in 
question. 
 The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a facility, it may 
be necessary to transport the beneficiary to another hospital or site temporarily for specialized care while the 
beneficiary maintains inpatient status with the original provider. This movement of the patient is considered 
patient transportation and is covered in the payment made to the facility. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulance transport have not been met. Specifically, the record shows that the enrollee maintained 
inpatient status at one facility from July 31, 2022, to August 23, 2022, which includes the date in question. This 
means that the services at issue are considered patient transportation and paid to the facility. Therefore, we 
decided that the Plan does not have to pay for ambulance transportation services (A0428, A0425) provided on 
August 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory assist device, bi-level pressure capability 
(E0472), and full-face mask used with positive airway pressure device (A7030) provided on January 5, 2023. 
 
You asked the Plan to pay for the durable medical equipment (DME). You say that your prescription for these 
items was never filled. You say that there was a shortage of equipment availability. You say that The Plan 
denied your request. The Plan says the provider in this case is not a Medicare certified provider. The Plan also 
says that payment cannot be made for items supplied by a provider that is not Medicare certified. 
 
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 the respiratory assist device, bi-level 
pressure capability (E0472), and full-face mask used with positive airway pressure device (A7030) provided on 
January 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the synthetic sheepskin pad and continuous passive motion 
exercise device provided on October 31, 2022, to November 20, 2022. 
 
You asked the Plan to pay for the synthetic sheepskin pad and continuous passive motion exercise device. You 
say that you disagree with the Plan's denial. 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. The documentation 
did not include a patient receipt or proof of delivery for the billed date of service. 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 the synthetic sheepskin pad and continuous passive motion exercise device 
provided on October 31, 2022, to November 20, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services billed for date of service 
May 31, 2022. 
 
You asked the Plan to pay for the outpatient mental health services. You say that you billed these services 
correctly. The Plan denied your request. The Plan says you billed these services with an invalid Place of 
Service code. 
 
The Plan must follow Medicare rules. Medicare rules say that Place of Service (POS) code 10 is not applicable 
for adjudication of Medicare claims. You billed the outpatient mental health services in dispute with POS code 
10, which is not correct. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient mental health services have not been met. Therefore, we decided that the Plan does 
not have to pay for outpatient mental health services billed for date of service May 31, 2022.
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 
January 13, 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 January 13, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services (00732) billed for date of service October 26, 2022. 
 
You asked the Plan to pay for anesthesia services. You say that the services at issue have been billed correctly. 
The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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. Specifically, the Plan's denial states that the code at issue is not payable to a non-
anesthesia provider. The case record documents that the provider at issue is a nurse anesthetist. The Plan has 
not provided a valid rationale to explain why the provider is not eligible for payment. It is the Plan's 
responsibility to substantiate its denial. In this case, the Plan's denial has not been supported, so we must find in 
your favor. Therefore, we decided that the Plan has to pay for anesthesia services (00732) billed for date of 
service October 26, 2022.  
 
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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve hearing aids (V5260 x2). 
 
You asked the Plan to pre-approve the hearing aids. You say that you have submitted medical evaluations that 
explain why you need to wear hearing aids, and are asking the Plan to reconsider your request. The Plan denied 
your request. The Plan says that this request cannot be approved. 
 
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 did not provide a copy of the applicable full 2023 Evidence of 
Coverage for this case. We asked for this document, but it was not provided to us. Without this information we 
cannot determine that the Plan's coverage rules support the Plan's denial in this case, or that the enrollee has 
been adequately notified of the Plan's coverage rules and benefits. Consequently, the Plan has not substantiated 
their denial in this case. Therefore, we decided that the Plan has to pre-approve hearing aids (V5260 x2).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full thickness graft, free, including direct closure of 
donor site (15260) and repair of ectropion, extensive (67917) provided December 2, 2022. 
 
You asked the Plan to pay for the surgical procedures. You say that you are appealing the denial for this case 
that you were called to assist the doctor who is an in-network provider. The Plan denied your request. The Plan 
says the CPT codes billed are not valid for assistant at surgery services. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) codes 15260 and 67917. The Medicare Fee Schedule Database contains a 
surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is 
not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage 
criteria for the surgical procedures have not been met. Therefore, we decided that the Plan does not have to pay for the full thickness graft, free, including direct closure of donor site (15260) and repair of ectropion, 
extensive (67917) provided December 2, 2022.
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 requesting an expedited reconsideration for 
the denial of an IRF admission. You say you feel you can return to your active lifestyle if you can get intensive 
therapy. The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to an 
IRF. 
 
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 have complex needs and you do not require frequent physiatry oversight 
or rehabilitation nursing.  
 
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 Xgeva (J0897). 
 
You asked the Plan to pre-approve Xgeva. The Plan denied your request. The Plan says this drug is not covered 
per Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Xgeva. Our reviewer says that Xgeva is 
not medically reasonable and necessary for the enrollee. Our physician reviewer found the Xgeva is not being 
prescribed for a medically accepted indication. Xgeva and Prolia are not interchangeable products. Our 
reviewer found that the requested use of Xgeva (J0897) is not FDA-approved for the enrollees diagnosis. Our 
physician reviewer also found that the use is not supported by one of the major drug compendia or by clinical 
research that appears in a Centers for Medicare & Medicaid Services (CMS) approved medical journal.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva (J0897).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0425, A0427) provided on July 20, 
2022. 
 
You asked the Plan to pay for ambulance services. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says the enrollee maintained inpatient 
status with one facility on the date in question. This means that payment for these services is included in the 
payment to the facility and not made separately. 
 
The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a facility, it may 
be necessary to transport the beneficiary to another hospital or site temporarily for specialized care while the beneficiary maintains inpatient status with the original provider. This movement of the patient is considered 
patient transportation and is covered in the payment made to the facility. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulance services have not been met. Specifically, the record shows that the enrollee maintained 
inpatient status at one facility from July 18, 2022, to July 23, 2022, which covers the date in question. This 
means that the services at issue are considered patient transportation and paid to the facility. Therefore, we 
decided that the Plan does not have to pay for ambulance services (A0425, A0427) provided on July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SPRINT peripheral nerve stimulator (PNS). 
 
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 chronic intractable pain 
in the right knee. A right genicular nerve block performed on March 8, 2023 provided 80 percent diagnostic 
pain relief. There is insufficient support in the medical literature for the use of the SPRINT peripheral nerve 
stimulator in the enrollee's setting. The services are therefore not reasonable or 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 a SPRINT peripheral nerve stimulator (PNS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Purewick external female catheters, accessory kit, and 
suction pump. 
 
You asked the Plan to pre-approve Purewick external female catheters, accessory kit, and suction pump. The 
Plan denied your request. The Plan says the requested Purewick external catheter is considered incontinence 
supplies. The Plan also says while incontinence supplies may be appropriate in this case, neither the Plan nor 
Medicare offers coverage of these items. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve Purewick external female 
catheters, accessory kit, and suction pump.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service from 
January 1, 2023, to January 28, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that the services at issue were billed correctly. 
The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service from January 1, 2023, to January 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 12-month supply allowance for a non-implanted 
continuous glucose monitor (CGM) system described by code A4238. 
 
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 cannot be separately approved. 
 
The Plan must follow Medicare rules. The rules say that code A4224 is all-inclusive and describes all necessary 
supplies used with an external infusion pump (E0784). 
 
We looked at the file and Medicare rules. The Plan has approved the non-implanted continuous glucose 
monitor described by code E0784. All necessary supplies are already approved with code A4224. The supplies 
requested with code A4238 cannot be separately approved. Therefore, we decided that the Plan does not have 
to pre-approve a 12-month supply allowance for a non-implanted continuous glucose monitor (CGM) system 
described by code A4238.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing, 81219 CALR (calreticulin). 
 
You asked the Plan to pre-approve genetic testing. 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 follows Medicare rules. Medicare rules say that for laboratories performing single gene technologies, 
a sequential genetic testing approach is expected. 
 
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 genetic testing. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the record sent by the provider 
indicates that the enrollee has had microcytic anemia that has been refractory to multiple iron infusions. The 
hematologist stated that he most likely has anemia of chronic disease and would order a myeloproliferative 
panel. Records do not indicate the enrollee has been tested previously for BCR-ABL. The review has 
determined that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing, 81219 CALR (calreticulin).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency evaluation and management (EM) services 
provided on November 16, 2022. 
 
You asked the Plan to pay for the EM services. You say that multiple exams were provided on this date. The 
Plan denied your request. The Plan says this is a duplicate claim. 
 
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 EM services have been met. The 
records do not show that two EM services were provided by the billing physician on the date at issue. The Plan 
has shown that payment was made for the services on a prior claim. There is no sufficient documentation to 
support payment for additional EM services. Therefore, we decided that the Plan does not have to pay for the 
emergency evaluation and management (EM) services provided on November 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99292 billed for date of service July 27, 
2022. 
 
You asked the Plan to pay for procedure code 99292. You say that the coding department reviewed the level of 
evaluation and concluded that the coding done was best. The Plan denied your request. The Plan says payment 
for code 99292 is bundled into payment for code 36556. 
 
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 99292 
is a column II code to column I code 36556. 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 code 99292 billed for date of service July 27, 2022.