Persius/hicric huggingface dataset:
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 the requested SNF services are medically necessary. The Plan denied your request. The Plan says 
it is not medically necessary for you to require daily in-patient physical occupational therapy and that your needs can be met with intermittent physical/occupational therapy 3 to 4 times per week at a lower level of care 
at home or a custodial level.  
 
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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided February 
8, 2023, to March 1, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the enrollee was treated for post-
surgical lymphedema. You disagree with this denial and believe these services were medically necessary. The 
Plan denied your request. The Plan says under Medicare guidelines, this request is not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided February 8, 2023, to March 1, 2023.
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 the enrollee requires admission to an 
LTACH. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for 
admission to an LTACH.  
 
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 already available in 
the current acute care setting. The enrollee can safely receive medically necessary care at the current facility 
until they are more stable for transfer to a lower 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 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 93005 billed for date of service June 4, 2023. 
 
You asked the Plan to pay for code 93005. You say that this is a payable code. The Plan denied your request. 
The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that STV-packaged services are services for which separate 
payment is made only if there is no service with status indicator S, T, or V reported on the same claim. If a 
claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged 
services are assigned status indicator Q1. In this case, the code in dispute has a status indicator of QI, meaning 
that it is a STV-packaged service.  This disputed code was billed on the same claim with a code that has a status indicator of S, T, or V.  This means that the code in dispute in this appeal is not separately payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 93005 have not been met. Therefore, we decided that the Plan does not have to pay for code 
93005 billed for date of service June 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service September 4, 
2023.  
 You asked the Plan to pay for procedure code 86077. You say that this service is supported as billed. 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 code 86077 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 code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service September 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided on May 
4, 2023, through May 23, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. 
The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided on May 4, 2023, through May 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite diabetic test strips (A4253). 
 
You asked the Plan to pre-approve Freestyle Lite test strips. You say that the requested items are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says only the preferred brand products listed 
in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non-preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for diabetic test strips. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite diabetic 
test strips (A4253).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0483 billed for date of service July 31, 2023. 
 
You asked the Plan to pay for procedure code G0483. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says that the provided records do not support the service 
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 G0483 is: Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual 
drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited 
to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., 
ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if 
performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the Plan states that the 
physician order for the services at issue does not order testing for 22 or more drug classes. We found that the 
provided records support an order for testing of 22 or more drug classes. Based on this information, we decided 
that Medicare rules for coverage of procedure code G0483 have been met. Therefore, we decided that the Plan 
has to pay for procedure code G0483 billed for date of service July 31, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this is experimental and therefore is not covered. 
 
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 CardioMEMS device. Our reviewer 
says that the requested CardioMEMS device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. Therefore, the reviewer 
found that the requested CardioMEMS device 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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of a CardioMEMS device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided on 
January 25, 2023, through January 28, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. 
The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided on January 25, 2023, through January 28, 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 SNF care is a medical necessity for the enrollee. 
The Plan denied your request. The Plan says the requested SNF care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on January 6, 2023. 
 
You asked the Plan to pay for the medical services. You say that you have been caught in an endless cycle of 
denials, and this claim should be reconsidered. The Plan denied your request. The Plan says you billed these 
services with a non-covered modifier. 
 
The Plan must follow Medicare rules. The rules say that modifiers from -HA through -HZ are non-covered by 
Medicare, and all services billed with these modifiers will be denied.  In this case, you billed the services in 
dispute with modifier -HE.  This modifier falls within the range of modifiers that are non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on January 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee's medical needs are being met in the current facility. There 
is no benefit to a lateral transfer. 
 
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 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's needs are being met at the current setting with no therapeutic benefit to 
an LTACH transfer. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit for the evaluation provided on 
April 10, 2023. 
 
You asked the Plan to pay for a home or residence visit for the evaluation. You say that the services should be 
covered. 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 a home or residence visit 
for the evaluation provided on April 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve temporary implantable nitinol device (TIND). 
 
You asked the Plan to pre-approve temporary implantable nitinol device (TIND). You say that the requested 
temporary implantable nitinol device (TIND) is medically necessary. The Plan denied your request. The Plan 
says the requested temporary implantable nitinol device (TIND) is experimental. 
 
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 temporary implantable nitinol device 
(TIND). Our reviewer says that the requested temporary implantable nitinol device (TIND) is not considered 
medically reasonable and necessary. Our physician reviewer found that the records do not show that the 
enrollee is not a candidate for or has not responded to medication or other minimally invasive therapies. The 
2023 American Urological Association (AUA) guideline update regarding iTIND states: iTind is an effective treatment option for men with benign prostatic hyperplasia (BPH)-related lower urinary tract symptoms 
(LUTS) who are not candidates for or who have not responded to medication or other minimally invasive 
therapies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of temporary implantable nitinol device (TIND) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve temporary implantable nitinol device (TIND).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 82565 billed for date of service August 29, 
2023. 
 You asked the Plan to pay for procedure code 82565. The Plan denied your request. The Plan says payment for 
code 82565 is bundled into payment for code 80053. 
 
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, we have confirmed that code 82565 
is a column II code to column I code 80053. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 82565 billed for date of service August 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on September 8, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says per Local Coverage 
Article A58726, this type of testing must be billed with a single unit of service of a single code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on September 8, 2023.