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

 
We decided that the Plan has to pre-approve a Freestyle Libre 3. 
 
You asked the Plan to pre-approve a Freestyle Libre 3. You say that the services are necessary. The Plan denied 
your request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a Freestyle Libre 3. Our reviewer says 
that the services are medically necessary. Our physician reviewer found the coverage criteria require low blood 
glucose (bgs) or insulin use; this enrollee has both and is an ideal candidate for the libre 3 CGM. 
 We looked at this physician's review, the file, and Medicare rules. The Freestyle Libre 3 is now a covered 
device, as it has been assigned the covered code of E2103 as of June 15, 2023. Based on this information, we 
decided that Medicare rules for coverage of a Freestyle Libre 3 have been met. Therefore, we decided that the 
Plan has to pre-approve a Freestyle Libre 3.  
 
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 pre-approve a bone marrow aspirate procedure (23909). 
 
You asked the Plan to pre-approve the bone marrow aspirate procedure. You say that this service is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has 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 the bone marrow aspirate procedure. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this procedure is still considered experimental for the enrollee's clinical 
situation. More research is needed to show safety and efficacy.  
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 bone marrow aspirate procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a bone marrow aspirate procedure (23909).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SI joint fusion (27279, 27280). 
 
You asked the Plan to pre-approve the SI joint fusion. You say that this surgery is medically necessary. The 
Plan denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an SI joint fusion is covered when all criteria listed in 
the Medicare rules section 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 the SI joint fusion. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that six months of conservative 
measures are not documented. Also, there is no SI joint instability, fracture, or lesion. SI joint fusion for 
degenerative back pain is experimental. 
 
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 SI joint fusion have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a SI joint fusion (27279, 27280).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does not have skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuation of SNF care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ure-na Packet 15GM. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. 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 Ure-na Packet 15GM.   
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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel for date of service April 21, 
2023. 
 
You asked the Plan to pay for the respiratory pathogen panel. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says these services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a respiratory pathogen panel test must not be 
unbundled and billed as individual components regardless of the fact that the panel reports multiple individual 
pathogens and/or targets. 
 
 
 
 We looked at the file and Medicare rules. Review of the file shows that this respiratory pathogen panel was 
unbundled and billed as individual components. Based on this information, we decided that Medicare rules for 
coverage of the respiratory pathogen panel have not been met. Therefore, we decided that the Plan does not 
have to pay for the respiratory pathogen panel for date of service April 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
(E0601) purchased on March 3, 2023. 
 
You asked the Plan to pay for the CPAP device. You say that the item was medically necessary. The Plan 
denied your request. The Plan says this item was purchased through a provider that is not enrolled in Medicare. 
 
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 continuous positive airway pressure 
(CPAP) device (E0601) purchased on March 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intermittent limb compression device. 
 
You asked the Plan to pay for the intermittent limb compression device. You say that the items were medically 
necessary. The Plan denied your request. The Plan says the records do not show that the enrollee has chronic 
lymphedema or chronic venous insufficiency 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for the intermittent limb compression 
device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 26, 2023, billed with 
evaluation and management code 99223. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid place of 
service. 
 The Plan must follow Medicare rules. Medicare rules say that the place of service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face-to-face service.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. This claim was inappropriately billed with 
place of service 21 as documentation shows the enrollee was registered outpatient observation on the date of 
service in question. Therefore, we decided that the Plan does not have to pay for practitioner services provided 
on March 26, 2023, billed with evaluation and management code 99223.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for OIVIT services (96365, 96366) provided on May 2, 2023. 
 
You asked the Plan to pay for OIVIT. You say that you have billed the services at issue correctly. The Plan 
denied your request. The Plan says rules for payment have not been met. 
 
  The Plan must follow Medicare rules. Medicare rules say that OIVIT is not reasonable and necessary for any 
indication. Based on this information, we decided that Medicare rules for coverage of OIVIT have not been 
met. Therefore, we decided that the Plan does not have to pay for OIVIT services (96365, 96366) provided on 
May 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 19, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable.  
 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 28, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this testing was necessary and is supported as 
billed. 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 I12.0 has an Excludes1 note in relation to I25.10. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for 
laboratory services provided on February 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99238 for date of service March 11, 2023. 
 
You asked the Plan to pay for procedure code 99238. 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 emergency department coding is not appropriate 
if the site of service is an office or outpatient setting or any sight of service other than an emergency 
department. 
 
We looked at the file and Medicare rules. Review of the file shows that procedure code 99238 was billed with a 
place of service 23 (Emergency room- Hospital). It is inappropriate to bill code 99238 with place of service 23. 
This service is not payable as billed. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99238 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99238 for date of service March 11, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95720 for date of service February 3, 2023. 
 
You asked the Plan to pay for procedure code 95720. You say that you disagree with the Plan's denial. 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 R56.9 (unspecified convulsions) has an Excludes1 note in relation to 
G40.901 (Epilepsy, unspecified, not intractable, with status epilepticus). This means that the two diagnosis 
codes cannot be reported together. Based on this information, we decided that the Medicare billing rules for 
procedure code 95720 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 95720 for date of service February 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing services (87641, 81003, 87500, 87653, 
87640, 87471 and 87798) provided on December 29, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that you have billed the services at issue correctly. 
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 code R39.15 has an Excludes1 note in relation to code N39.41. This means 
that the two diagnosis codes cannot be reported together. Based on this information, we decided that the 
Medicare billing rules for laboratory testing have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory testing services (87641, 81003, 87500, 87653, 87640, 87471 and 87798) provided on 
December 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services rendered on January 6, 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 claim was not billed with the correct National Provider Identification (NPI) number. 
 
The Plan must follow Medicare rules. The rules say that the entitys National Provider Identification (NPI), 
when required, is entered in block 33a of the claim form. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the correct NPI 
number. 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 pay for the assistant surgeon services rendered 
on January 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93306 rendered on March 6, 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 93306-26 (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 93306 is "Echocardiography, transthoracic, real-time 
with image documentation (2D), includes M-mode recording, when performed, complete, with spectral 
Doppler echocardiography, and with color flow Doppler echocardiography." 
 
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 this CPT code includes M-mode recording with spectral Doppler echocardiography and color flow Doppler echocardiography. A review of the 
available records does not verify the billed services in this case. In summary, the documentation does not 
support the appropriateness of CPT code 93306 in this enrollee. 
 
 
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 93306 rendered on March 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on February 13, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on February 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the continuous positive airway pressure (CPAP) 
supplies purchased January 19, 2022. 
 
You asked the Plan to reimburse you for the CPAP supplies. You say that you got a referral for the supplies 
while you were in Las Vegas and did all the proper steps for reimbursement. The Plan denied your request. The 
Plan says the supplies was purchased from a supplier that does not participate with Medicare. 
 
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 reimburse you for the continuous positive 
airway pressure (CPAP) supplies purchased January 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 29, 2022, to 
April 26, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct condition 
code.  
The Plan follows Medicare rules. The rules say that if the claim is for a period of care in which there are no 
skilled HH visits in the billing period, but a policy exception that allows billing for covered services is 
documented at the HHA, the HHA enters condition code 54. 
 
We reviewed the file and the Medicare rules. Review of the file shows that the home health agency reported 
medical social services home health care discipline (code G0155) without reporting a skilled nursing visit. 
Condition code 54 was not reported with the billed services. 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 March 29, 2022, to April 26, 2022.