Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 52352 and 99223 for date of service 
October 28, 2022. 
 
You asked the Plan to pay for procedure codes 52352 and 99223. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 52352 is not supported in the medical record. Specifically, the documentation indicates 
that a diagnostic cystourethroscopy was performed. There is a more appropriate code to be billed for the 
services rendered. We looked at the file and Medicare rules. Review of the file shows that surgery procedure 
52352 was provided on October 28, 2022. Code 52352 has a global surgery value of 0 days. Code 99223 was 
billed within the global surgery period of procedure 52352 without an appropriate modifier. This means code 
99223 is not separately payable as billed.  
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 52352 and 99223 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 52352 and 
99223 for date of service October 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the portable oxygen concentrator (POC) electric 
rechargeable battery (E1356). 
 
You asked the Plan to pre-approve the electric rechargeable battery . You say that you were told that you would 
receive 2 batteries with your portable oxygen concentrator. You will be traveling, and you need a second 
battery because it is a 7-to-8-hour trip in the car. The Plan denied your request. The Plan says an extra set of 
batteries is not a covered benefit. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that a portable oxygen concentrator was approved 
June 2023. Medicare does not provide coverage for POC batteries as the item itself, the POC, can be recharged. 
When a POC is authorized, it includes the device itself, and an integrated battery or beneficiary- replaceable 
battery. Medicare does not cover an extra set of batteries, or a double battery. Based on this information, we 
decided that Medicare rules for coverage of the electric rechargeable battery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the portable oxygen concentrator (POC) electric 
rechargeable battery (E1356).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing billed for date of service August 25, 2022. 
 
You asked the Plan to pay for the billed services. You say that the medical records prove medical necessity. 
The Plan denied your request. The Plan says that the service does not meet the coverage requirements.  
 
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 services at issue did not meet the requirements in the applicable Local Coverage Determination or National 
Coverage Determination. The Plan did not provide any rule that substantiates their denial. The Plan did not 
elaborate on their decision to deny the services at issue. 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 lab testing billed for date of service August 25, 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 pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration as the enrollee currently meets LTACH admission criteria. The Plan denied your request. The 
Plan says the requested service is not medically necessary.  
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the 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: Unfavorable

 
We decided that the Plan does not have to pay for the train of four testing (95999) provided on July 29, 2022 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says train of four testing is 
bundled and not separately reportable. 
 
The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure 
are considered bundled into that procedure and, therefore, are considered a component part of the 
comprehensive code.  
 
We looked at the file and Medicare rules. The train of four testing in this case is considered integral to the 
procedure and payment is bundled into the procedure. Separate payment cannot be made for train of four 
testing. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the train of four testing (95999) provided on 
July 29, 2022
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you do not feel you will recover without 
professional help. You say you want everything that can be done to be done so you have a possibility to 
recover. The Plan denied your request. The Plan says the SNF services requested do not meet the requirements 
for approval.  
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting.  
Although further rehabilitation services would be appropriate to improve function, the intermittent skilled 
services can be provided at a lower level of care than a skilled nursing facility. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for December 29, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the billed diagnosis codes are not appropriate. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that code 99232 was billed with two diagnosis codes 
that exclude each other. 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 procedure code 99232 
billed for December 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment, code E0217, billed for dates 
of service December 10, 2022, to December 30, 2022. 
 You asked the Plan to pay for the billed services. You say that medical literature shows the efficacy of the 
treatment rendered. The Plan denied your request. The Plan says the services are excluded from coverage. 
 
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 E0217 is water circulating heat pad with pump. We find 
that CPT code E0217 is not supported in the medical record. The records show that a pneumatic compression 
device was provided. There is a more accurate code that describes the provided equipment. The device was 
provided as a preventative service, which is not payable. 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 the durable medical equipment, code E0217, billed for dates of service December 10, 2022, to 
December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on November 28, 2022. 
 
You asked the Plan to pay for the wound care supplies. You say that these supplies are separately billable. The 
Plan denied your request. The Plan says these items are included in a Part A skilled nursing facility payment. 
 
The Plan must follow Medicare rules. Medicare rules say that any DME furnished to inpatients in a covered 
Part A stay is included in the SNF PPS rate. 
 
 We looked at the file and Medicare rules. The record shows these supplies were provided during an approved 
Part A SNF stay and are not separately payable. Therefore, we decided that the Plan does not have to pay for 
the wound care supplies provided on November 28, 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 reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the enrollee does not fit the guidelines required 
for an IRF stay. 
 
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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided December 16, 
2022, to January 9, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says the required services could have been provided at a 
lower level of care. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found documentation revealed that at the end of December 19, 2022, the enrollee was 
afebrile without confusion or bacteremia without a history of kidney or bladder surgery that might increase 
risk, and she was responding to treatment. She could have been discharged to a lower level of care at that time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided December 16, 2022, to January 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 billed for date of service 
March 16, 2023. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the charges. The 
Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. The records show that the enrollee received outpatient intravenous insulin 
therapy. The services are non-covered and not payable. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 96365 and 96366 billed for date of service March 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601) and miscellaneous durable medical equipment (E1399). 
 
You asked the Plan to pre-approve a mini-CPAP device. You say that you will be traveling back to Africa on 
July 7 , 2023 and you need this device to breathe better while sleeping and to use it on the air plane. The Plan 
denied your request. The Plan says mini-CPAP machines are not a covered benefit with Medicare. DME used 
for travel is not a covered benefit. 
 The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have Continuous positive airway pressure (CPAP) device received March 2019. 
Continuous positive airway pressure (CPAP) device received March 2019 serves the same purpose as a mini-
CPAP device. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway 
pressure (CPAP) device (E0601) and miscellaneous durable medical equipment (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-pneumatic compression controller with sequential 
calibrated gradient pressure (K1024) and non-pneumatic sequential compression garment (K1033) to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve Dayspring Active compression system and garment. You say that the 
Dayspring device is the only device that delivers tri-modal therapy and is deemed medically necessary by the 
physician. The Plan denied your request. The Plan says enrollees must receive their medical services from an 
in-network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a non-pneumatic compression controller with sequential calibrated gradient pressure (K1024) and non-
pneumatic sequential compression garment (K1033) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 for date of service February 14, 2023. 
 
You asked the Plan to pay for procedure code 99223. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this service is not payable as 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. 
 
 
 In this case, the CPT Code Manual definition of code 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 
We find that CPT code 99223 is not payable as billed. Specifically, the documentation shows that the enrollee 
was in outpatient observation. Procedure code 99223 was billed with place of service 21 (inpatient). Therefore, 
the claim is not payable as billed. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99223 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99223 for date of service February 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a cardiac contractibility modulation 
(CCM) system. 
 
You asked the Plan to pre-approve the CCM system. You say that the procedure is medically necessary as the 
enrollee suffers from high burden of symptoms as a result of chronic heart failure and is not indicated for any 
other approved therapy at this time. You also say that without the CCM system the enrollee's prognosis is poor. 
The Plan denied your request. The Plan says the requested CCM system is 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 the CCM system. Our reviewer says 
that the requested CCM system is not considered medically reasonable and necessary in this case. Our 
physician reviewer found CCM remains the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous 
studies are completed, it is premature to presume clinical outcomes and benefit. Therefore, the reviewer found 
that the CCM system is not medically necessary at this time. 
 
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 CCM system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve implantation of a cardiac contractibility modulation (CCM) system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 billed for November 16, 2021. 
 
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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on October 18, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure code J3490 billed for November 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on December 13, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 indicates 
that the two conditions cannot occur together.  
 
We looked at the file and Medicare rules. The claim in this case was billed with diagnosis codes R41.82 and 
R40.20. Diagnosis code R41.82 has an Excludes1 note and cannot be billed with R40.20. 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 the ambulance services provided on December 13, 2022.