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

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E0955, E2603, E1007, E1012, E2361, 
E1028, E2311, E2313, and E2377) 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
The Plan denied your request. The Plan says the enrollee does not have a neurological condition, myopathy or 
congenital skeletal deformity which is causing mobility impairment for which a Group 3 power wheelchair is 
reasonable and necessary. The Plan also says the enrollee's mobility impairment is due to diabetes and chronic 
obstructive pulmonary disease, and the enrollee does not meet the criteria for base code group 3 power 
wheelchair. 
 The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 standard power wheelchair with multiple power options (K0861) and additional items and accessories 
(codes E0955, E2603, E1007, E1012, E2361, E1028, E2311, E2313, and E2377)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you are appealing this denial. 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 foot orthotics.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing (0117U) provided on September 22, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says that this code is excluded from coverage 
according to Local Coverage Articles A58812 and A58801. 
 
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 two Local Coverage Articles (LCA) cited by the Plan do not 
apply to the state where these services were performed. Local Coverage Article: Billing and Coding: MolDX: 
Pharmacogenomics Testing (A58324) has jurisdiction over the state where this testing was performed, and this 
article includes no such rule for exclusion of this code. The Plan has not provided adequate evidence to support 
their denial in this case. Therefore, we decided that the Plan has to pay for laboratory testing (0117U) provided 
on September 22, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 23, 2022, to 
August 25, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code J96.01, described as 
Acute respiratory failure with hypoxia. 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 
inpatient hospital services at the DRG originally billed. Our reviewer says that documentation does not support 
the billed code. Our physician reviewer found the enrollee is a 77-year-old female who presented with 
trigeminal neuralgia and planned intervention. She was treated with a rectosigmoid craniotomy and 
decompression of the 5th nerve. It was reported that she had periods of hypoxia post-operatively and was 
treated with low dose oxygen and eventually weaned down to room air by discharge date. The provided records 
did not show evidence of the enrollee requiring or receiving high flow oxygen support, bilevel positive airway 
pressure, or vent support to treat any acute respiratory failure.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 23, 2022, to August 25, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eyelid/eyebrow surgery. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the information from the provider did not include photographs of the MRD 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the photos provided does not demonstrate a marginal reflex distance (MRD) of less than 2mm. The 
enrollee does not meet criteria for this request. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve eyelid/eyebrow surgery.
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 January 3, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. 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 January 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 9, 2022, 
to January 7, 2023. 
 You asked the Plan to pay for the home health services. You say that your original NOA was submitted with 
the incorrect admission date, and a correct one has been rebilled. The Plan denied your request. The Plan says 
the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is December 9, 2022. The NOA was not received by the Plan until February 
15, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from December 9, 2022, to January 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interrogation device evaluation(s) (remote), up to 90 
days: single, dual, or multiple lead pacemaker system, or leadless pacemaker system with interim analysis, 
review(s) and report(s) by a physician or other qualified health care professional, provided on January 12, 
2023. 
 
You asked the Plan to pay for the interrogation device evaluation. You say that the service should be covered. 
The Plan denied your request. The Plan says this code was billed twice within 90 days. 
 
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 93294 is interrogation device evaluation(s) (remote), up 
to 90 days: single, dual, or multiple lead pacemaker system, or leadless pacemaker system with interim 
analysis, review(s) and report(s) by a physician or other qualified health care professional. 
 
We find that CPT code 93294 is not supported in the records submitted. Specifically, this code is not allowed 
more than once in a 90-day period. This service was last received on October 16, 2022, making the service at 
issue less than 90-days from the last billed. Based on this information, we decided that Medicare rules for coverage of the interrogation device evaluation have not been met. Therefore, we decided that the Plan does not 
have to pay for the interrogation device evaluation(s) (remote), up to 90 days: single, dual, or multiple lead 
pacemaker system, or leadless pacemaker system with interim analysis, review(s) and report(s) by a physician 
or other qualified health care professional, provided on January 12, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the records do not show the enrollee has a daily skilled 
nursing or daily rehabilitation need.  
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily 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 SNF care.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of soft tissue of the neck with 
contrast. 
 
You asked the Plan to pre-approve a CT scan of the neck. You say that you disagree with the denial and have 
faxed documents to support medical necessity. The Plan denied your request. The Plan says that the clinic notes 
of the treating physician does not indicate the rationale for the CT scan. There is a lack of sufficient clinical 
documentation of differential diagnosis, test's impact on decision-making, and additional clinical evidence that 
all more conservative measures have been used. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the neck. Our reviewer 
says that the service is medically necessary. Our physician reviewer found during the visit to an ENT on June1, 
2023 it is noted the patient complains of sore throat and has unilateral vocal cord paralysis.  Given these 
symptoms the request for CT of the neck is reasonable. 
 
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 CT scan of the neck have been met. Therefore, we decided that the Plan has to 
pre-approve a computed tomography (CT) scan of soft tissue of the neck with contrast.  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is the only option for the 
enrollee due to the need for frequent nursing and respiratory care. The Plan denied your request. The Plan says 
the LTACH services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving acute hospital care, and acute care services have not been 
denied. The documentation shows there are no required medical services identified that are available at the 
LTACH, that are not available at the current health care setting being offered by the health plan. 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve Y-90 radioembolization. 
 
You asked the Plan to pre-approve Y-90 radioembolization. You say that there is urgency to the enrollee's 
situation as she has demonstrated rapid disease progression in the liver. The Plan denied your request. The Plan 
says that a SIRT/ablative approach here is not actually unproven, it's actually proven to be of no benefit 
medically/oncological. The request does not meet the Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 Y-90 radioembolization. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has unresectable metastatic disease to the liver from breast cancer. SIRT 
has typically been used in enrollees with other primary tumors, but the requesting physician has provided 
references that support the use of this therapy in other types of primary tumors including breast. Since the 
enrollee has no other viable option for treatment of her advancing unresectable liver metastases, the request is 
reasonable based upon submitted supporting literature by the requesting physician and should be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Y-90 radioembolization have been met. Therefore, we decided that the Plan has 
to pre-approve Y-90 radioembolization.  
 
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 procedure code 64708 billed for date of service November 
10, 2022. 
 
You asked the Plan to pay for procedure code 64708. You say that this service was billed separately and should 
be paid. The Plan denied your request. The Plan says this service is included in the 90-day global surgery 
period for other procedures billed by the same physician for date of service October 13, 2022. Separate 
payment is not due in this case. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules state that if an unrelated surgical procedure is performed by the same physician during a postoperative 
period, the physician may need to indicate that the later surgery is unrelated to the original procedure. Modifier 
79 is used to report unrelated services.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 64708 have not been met. Specifically, this service was billed within the 90-day 
global surgery period of codes 22212 and 22610 which were billed by the same physician for a date of service 
of October 13, 2022. The service at issue was not billed with modifier 79 to indicate that it is unrelated to and 
therefore not included in the global surgery package for these previous procedures. Therefore, we decided that 
the Plan does not have to pay for procedure code 64708 billed for date of service November 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 23, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the test should not be 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable.  
 
 Laboratories should bill the facility directly for laboratory services as they are considered part of the composite 
rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay 
for the laboratory services related to end-stage renal disease (ESRD) provided on January 23, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 24, 2022, 
to January 22, 2023. 
 You asked the Plan to pay for the home health services. You say that the NOA was submitted late due to the 
delay in certification with Medicare. The Plan denied your request. The Plan says the NOA was not received 
timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 25, 2022. The NOA was not received by the Plan until December 
6, 2022. The information you submitted shows your change of ownership was approved prior to the start of 
care date. There is no indication that your circumstances qualify for a waiver of the timely filing requirement. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for the home health services provided from 
December 24, 2022, to January 22, 2023.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health care billed for dates of service October 20, 2022, to 
November 16, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim was billed according to Medicare 
guidelines. The Plan denied your request. The Plan says that a description of the billed codes was not provided. 
 
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. 
 
We looked at the file and the rules. The home health care services were billed with the appropriate codes as 
outlined in Medicare guidelines. The rules do not show that a description of the code is required. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request.  Therefore, we decided that the Plan has to pay for the home health care billed for dates of 
service October 20, 2022, to November 16, 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.