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

 
We decided that the Plan does not have to pay for the hospital bed provided on August 01, 2023. 
 
You asked the Plan to pay for the hospital bed. You say that the item was 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 hospital bed 
provided on August 01, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 18, 2023, billed with 
codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81403, 81404, 81405, 81406, 81407, 
81408 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 18, 2023, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81403, 
81404, 81405, 81406, 81407, 81408 and 81479.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent transport services from the hospital to the 
assisted living facility provided on August 7, 2023. 
 
You asked the Plan to pay for the non-emergent transport services. You say that the enrollee was bed confined, 
confused, and was at risk of fall, due to their condition at the time of transport and any other means of transport 
would have been unsafe. The Plan denied your request. The Plan says transportation could have been provided 
by other means. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
 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 non-emergent transport services. Our 
reviewer says that the transport services were not medically necessary. Our physician reviewer found the 
enrollee was reportedly bed bound but was sitting on the bed when they reached down for something causing 
the fall. Per emergency room note, the enrollee was alert and oriented and there was no evidence of confusion. 
Therefore, the enrollee could have safely been transported via stretcher van. The enrollee did not require a 
higher-level of transport personal.  
 
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 non-emergent transport services have not been met. Therefore, we decided 
that the Plan does not have to pay for the non-emergent transport services from the hospital to the assisted 
living facility provided on August 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on June 27, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the drug testing rendered on June 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Nova Zoom rollator walker. 
 
You asked the Plan to pre-approve a walker. You say that you need the walker to use. The Plan denied your 
request. The Plan says the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a walker have been met. clinical notes 
and the required signed doctor's order was needed. The records show that the Plan made multiple attempts to obtain the clinical notes and the required signed order without success. Therefore, we decided that the Plan 
does not have to pre-approve a Nova Zoom rollator walker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs for a power mobility device. 
 
You asked the Plan to pre-approve repairs. You say that there have not been any repairs billed for this 
equipment. You say that the repairs are reasonable due to normal wear and tear. The Plan denied your request. 
The Plan says the cost of the repairs is more than the cost of a replacement device. 
 
The Plan must follow Medicare rules. Medicare rules say that if the expense for repairs exceeds the estimated 
expense of purchasing or renting another item of equipment for the remaining period of medical need, no 
payment can be made for the amount of the excess. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of repairs have not been met. Therefore, we decided that the Plan does not have to pre-approve repairs 
for a power mobility device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on January 
27, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that this was a preventative 
service, and should be fully covered. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for doctors visits. 
 
You have been asked to pay a $30 copayment for a specialist office visit. This item/service falls within the 
doctors visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit 
provided on January 27, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lyumjev. 
 
You asked the Plan to pre-approve Lyumjev. You say that the enrollee has now tried Fiasp for three months 
and Novolog for five years. The Plan denied your request. The Plan says that self-administered drugs do not 
fall under Medicare Part B coverage. 
 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 Lyumjev.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the non-emergent ambulance transport services from the hospital to the 
assisted living facility where the enrollee resided provided on July 5, 2023. 
 
You asked the Plan to pay for the non-emergent transport services. You say that at the time of transport the 
enrollee was confused, bed confined, experiencing weakness and had an altered mental status due to their 
condition, any other means of transport would have been unsafe. The Plan denied your request. The Plan says 
that the services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergent transport services. Our 
reviewer says that the non-emergency transport services were medically necessary. Our physician reviewer 
found the enrollee required trained personal and equipment for transport on July 5, 2023, that only a fully-
equipped ambulance can provide for safe transport. The documentation supports that the ambulance transport 
services were medically reasonable and necessary on this date. 
 
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 non-emergent transport services have not been met. Therefore, we decided 
that the Plan has to pay for the non-emergent ambulance transport services from the hospital to the assisted 
living facility where the enrollee resided provided on July 5, 2023.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) (E0651) and 
appliance (E0667). 
 
You asked the Plan to pre-approve the PCD and appliance. The Plan denied your request. The Plan says the 
coverage criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that a PCD coded E0651 is covered when the criteria in 
the applicable LCD 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 PCD and appliance. Our reviewer 
says that the requested PCD and appliance are not medically reasonable and necessary. Our physician reviewer 
found that there is no documentation of prior treatment with physical therapy, compression stockings, or leg 
elevation, as required by the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PCD and appliance have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a pneumatic compression device (PCD) (E0651) and appliance (E0667).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36415, 84439, 84443, & 85025 provided on 
March 14, 2023. 
 
You asked the Plan to pay for procedure codes 36415, 84439, 84443, & 85025. You say that these services 
were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT codes 36415, 84439, 84443, & 85025 are not supported in the medical record. Specifically, 
the claim did not include a payable professional component, therefore these services are not payable under the 
Physician Fee Schedule. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 36415, 84439, 84443, & 85025 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes 36415, 84439, 84443, & 85025 provided on March 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator, portable oxygen system, 
alternating pressure pad, semi-electric hospital bed, heavy duty front wheeled walker, and commode chair to be 
delivered outside of the Plan's service area. 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that you just had surgery. 
You also say that you need this DME so that you can recover your mobility. The Plan denied your request. The 
Plan says the items are not eligible for delivery outside of the Plan's service area. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the durable medical equipment (DME) have not been met. The record shows that you are currently 
residing outside of the Plan's covered service area. The Evidence of Coverage clearly states that for DME items to be covered, they need to be provided inside of the service area. Therefore, we decided that the Plan does not 
have to pre-approve an oxygen concentrator, portable oxygen system, alternating pressure pad, semi-electric 
hospital bed, heavy duty front wheeled walker, and commode chair to be delivered outside of the Plan's service 
area.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the vascular studies provided on October 
18, 2022. 
 
You asked the Plan to waive the copayment for the vascular studies. You say that you were told that you only 
have a $60 cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $90 copayment for the vascular studies. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the vascular studies provided on October 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance service basic life support 
emergency transport (A0429RH) provided on July 6, 2023 and pay for the unlisted ambulance service 
(A0999RH) provided on July 13, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation (A0429RH) and unlisted 
ambulance services (A0999RH). You say that you disagree with the denial and would like the plan to 
reconsider payment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for each covered, one-way ambulance trip by ground or water.   
 
You have been asked to pay a $200 copayment for the ambulance transportation. This item/service falls within 
the ambulance service benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance service basic life support emergency transport (A0429RH) provided on July 6, 2023. 
 
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 A0999RH has a status indicator of X on the Physician Fee Schedule. This means 
that procedure code A0999RH is excluded and not eligible for payment. Based on this information, we decided 
that Medicare rules for coverage of procedure code A0999RH have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code A0999RH billed for date of service July 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient clinic visits for assessment and management 
to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve outpatient clinic visits for assessment and management. You say that you 
are requesting reconsideration for the denied claim. The Plan denied your request. The Plan says this provider 
is out-of-network, and the services could be performed in-network. 
 
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 
outpatient clinic visits for assessment and management to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied CGM and that the services requested are medically necessary. The Plan 
denied your request. The Plan says the criteria for approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64494-LT and 64494-59-RT billed for date 
of service March 24, 2023.  
 You asked the Plan to pay for procedure codes 64494-LT and 64494-59-RT. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT codes 64494-LT and 64494-59-RT is 1. The MAI value for this code is 2. You 
billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 64494-LT and 64494-59-RT have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 64494-LT and 64494-59-RT billed for date of service March 24, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vascular compression unit (VCU) system provided on 
March 27, 2023, to April 13, 2023. 
 
You asked the Plan to pay for the vascular compression unit (VCU) system. You say that the item was 
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 vascular 
compression unit (VCU) system provided on March 27, 2023, to April 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88312 billed for date of service July 28, 
2023.  
 
You asked the Plan to pay for procedure code 88312. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88312 is 9. The MAI value for this code is 3. You billed 14 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88312 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88312 billed for date of service July 28, 2023.