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

 
We decided that the Plan does not have to pay for codes 87486, 87496, 87498, 87532, 87541, 87581, 87640, 
and 87798 for date of service April 6, 2023. 
 
You asked the Plan to pay for codes 87486, 87496, 87498, 87532, 87541, 87581, 87640, and 87798. 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 a respiratory pathogen panel test is a single 
service with a single unit of service (UOS=1). 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 a respiratory pathology panel was 
ordered and performed. The services were not billed as a single service as required. Based on this information, 
we decided that Medicare rules for coverage of codes 87486, 87496, 87498, 87532, 87541, 87581, 87640, and 
87798 have not been met. Therefore, we decided that the Plan does not have to pay for codes 87486, 87496, 
87498, 87532, 87541, 87581, 87640, and 87798 for date of service April 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 03, 2023. 
 
You asked the Plan to pay for lab services. You say that the enrollee was in a nursing home at the time the 
services were rendered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab services provided on 
May 03, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upgraded electronics, height adjustable push handles, 
and U-shape handle. 
 
You asked the Plan to pre-approve the upgraded electronics and handles. You say that this is medically 
necessary for the enrollee. The Plan denied your request. The Plan says there is not a medical need to control 
these power options through the joystick. The Plan also says push handles do not serve a medical purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a 
medical purpose. 
 
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 upgraded electronics and handles. 
Our reviewer says that the requested upgraded electronics are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided documentation indicates that the enrollee 
does have use of the upper extremity and can operate and control the power options using the switches that are 
included in the basic wheelchair. There is not a medical need for the upgraded electronics. Therefore, the 
reviewer found that the request for upgraded electronics is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the upgraded electronics have not been met. Additionally, the requested handles 
do not serve a purpose that is primarily medical in nature. These items are available to the general public and 
would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have 
to pre-approve upgraded electronics, height adjustable push handles, and U-shape handle.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 11, 2021, to 
August 17, 2021, 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 
medical records support the DRG billed. The Plan denied your request. The Plan says The billed secondary 
diagnosis of J96.01 (acute respiratory failure with hypoxia) is not supported in the medical record. There was 
no administration of oxygen, 5L or more, provision of bilevel positive airway pressure (BiPAP) and/or 
mechanical ventilation, documentation of respirations greater than 24, accessory muscle use documented by a 
physician or altered mental status secondary to hypoxia. As a result, a lower DRG was paid. 
 
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 a secondary diagnosis of J96.01 (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 the billed secondary diagnosis of J96.01 (acute 
respiratory failure with hypoxia) is not supported in the medical record. Our physician reviewer found the 
enrollee is an 80-year-old with a history of congestive heart failure (CHF) who presented with shortness of 
breath on exertion for a few days. His evaluation suggested a diagnosis of pneumonia or exacerbation of CHF 
and he was admitted to the hospital for further care. The enrollee did have documentation of hypoxia with an 
oxygen saturation of 89% at urgent care, prior to his presentation to the emergency department. However, at 
the time of his evaluation at the emergency department and subsequent course, he was not documented to be in 
significant respiratory distress, nor was he hypoxic, nor did he require oxygen at a level of 5l/min nasal cannula 
or bilevel positive airway pressure (BiPAP) support, all specific requirements to support a secondary diagnosis 
of acute respiratory failure with hypoxia.  
 
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 11, 2021, to August 17, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
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 your leg gives out when walking, nurses/therapists 
want me to get my foot amputated again and that is fine, its even more money. The Plan denied your request. 
The Plan says your records do not show that you have a complex medical problem that can only be treated in 
an inpatient acute rehabilitation program.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve traction equipment, cervical, free-standing stand/frame, 
pneumatic, applying traction force to other than mandible (E0849). 
 
You asked the Plan to pre-approve a cervical traction device. You say that the device is medically necessary. 
The Plan denied your request. The Plan says the records do not meet Medicare guidelines that show a medical 
reason why the enrollee needs the purchase of a cervical traction device. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a cervical traction device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has cervical radiculopathy. There is no need for this free-standing device. 
An off the shelf cervical traction over the door type unit will be fine. 
 
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 cervical traction device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve traction equipment, cervical, free-standing stand/frame, pneumatic, applying 
traction force to other than mandible (E0849).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on February 10, 2023. 
 
You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the nursing facility care 
provided on February 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0483) provided on August 9, 2022. 
 
You asked the Plan to pay for drug testing G0483. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the records do not include a clear intent to order this specific lab 
service. 
 The Plan must follow Medicare rules. Medicare rules say that all diagnostic laboratory tests must be 
specifically ordered by the physician that is treating the beneficiary.  
 
We looked at the file and Medicare rules. Although there is a lab requisition form included in the records, the 
form requests a proprietary lab panel without specification of the drug classes to be tested or a definition of the 
proprietary panel. Therefore, it has not been supported that the enrollees treating physician specifically 
ordered G0483 testing. Based on this information, we decided that Medicare rules for coverage of drug testing 
G0483 have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) 
provided on August 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD) (E0483). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the device is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the request is not medically necessary because the 
records do not show a diagnosis of cystic fibrosis, bronchiectasis, or a neuromuscular disease. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a HFCWOD. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has COPD with cough and 
mucus production. The most recent chest computed tomography (CT) on May 30, 2023, does not indicate 
bronchiectasis. There is no diagnosis of cystic fibrosis or neuromuscular disease. COPD is not a diagnosis for 
which Medicare covers the high-frequency chest wall oscillation device, because its benefit has not been 
established in the treatment of enrollees with this disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD) (E0483).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam provided on February 21, 2023. 
 
You asked the Plan to pay for the eye exam. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the eye exam provided 
on February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam provided on June 6, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the eye exam. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says the service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the eye exam provided on June 6, 2023, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 10, 2023. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on April 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 49553 billed for date of service February 26, 
2022. 
 You asked the Plan to pay for the billed services. You say that the diagnosis code was correct. The Plan denied 
your request. The Plan says the appropriate modifier was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The file shows that code 49553 was billed with diagnosis code K41.30, unilateral femoral hernia, with 
obstruction. We find that CPT code 49553 is not supported. The medical records show that a repair of a right 
femoral hernia was provided. The code was not billed with a modifier indicating which side of the body the 
services were provided on. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 49553 
billed for date of service February 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ondansetron.  
You asked the Plan to pre-approve the medication. You say that the requested drug is medically 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 drug ondansetron requested here is not among the types which are 
covered by Medicare Part B. Although an oral anti-emetic such as ondansetron may be covered by Medicare 
Part B, this request does not fall under Medicare Part B coverage because the enrollee may need the drug 
longer than 48 hours. Additionally, it has not been indicated that ondansetron is a full replacement for 
intravenous anti-emetics. Therefore, we decided that the Plan does not have to pre-approve ondansetron.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the enrollee has received 90% relief 
on the right knee from genicular block. The Plan denied your request. The Plan says the requested procedure 
does not meet the requirements for approval. 
 
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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this procedure is the subject of ongoing clinical trials and is considered 
experimental/ investigational. Therefore, the request is deemed not medically reasonable and 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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic facet joint injection. 
 
You asked the Plan to pre-approve a therapeutic facet joint injection. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is not 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 therapeutic facet joint injection. Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has not 
met the requirement for a confirmed therapeutic facet joint injection because he has only had one previous 
injection that did not provide adequate pain relief. The review has determined that the enrollee does not meet 
the LCD criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapeutic facet joint injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a therapeutic facet joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 15, 2023, billed with 
procedure codes 96365-59, 96366-59, and 96521. 
 
You asked the Plan to pay for the practitioner services provided. You say that that the claim is billed correctly 
and should be paid. The Plan denied your request. The Plan says documentation does not support the billed 
codes. 
 
The Plan must follow Medicare rules. Medicare rules say that effective for claims with dates of service on and 
after December 23, 2009, the Centers for Medicare and Medicaid Services (CMS) determines that the evidence 
is adequate to conclude that outpatient intravenous (IV) insulin therapy (OIVIT) does not improve health outcomes in Medicare beneficiaries. Therefore, CMS determines that OIVIT is not reasonable and necessary 
for any indication under section 1862(a)(1)(A) of the Social Security Act. Services comprising an Outpatient 
Intravenous Insulin Therapy regimen are nationally non-covered under Medicare when furnished pursuant to an 
OIVIT regimen. You can find this rule in the National Coverage Determination (NCD) - Outpatient 
Intravenous Insulin Treatment (40.7). 
 
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. The billed services are not payable as this is a 
non-covered service. Therefore, we decided that the Plan does not have to pay for practitioner services 
provided on May 15, 2023, billed with procedure codes 96365-59, 96366-59, and 96521.