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

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve spinal cord stimulator. You say that the enrollee has tried and failed 
multiple therapies and would benefit from a stimulator. The Plan denied your request. The Plan says the 
records show that the enrollee has not had screening, evaluation, and diagnosis by a multidisciplinary team 
prior to implantation. 
 The Plan follows Medicare rules. Medicare rules state that electrical nerve stimulators may be covered if 
certain criteria 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 spinal cord stimulator. Our reviewer 
says that the enrollee does not meet criteria for a spinal cord stimulator. Our physician reviewer found this is 
considered experimental therapy for diabetic peripheral neuropathy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 9, 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 the services were not billed correctly. 
 
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 laboratory services rendered on August 9, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to the LTACH is a medical 
necessity. The Plan denied your request. The Plan says according to the information reviewed on appeal, 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 appeal for LTACH notes that the primary reason for LTACH admission is 
encephalopathy, though it does not appear that this will be better, indeed, progress note on December 4, 2023, 
notes that the enrollee is alert and oriented times three. The enrollee is on total parenteral nutrition, tough it 
appears this can be weaned as they are able to swallow thick liquids and was started on a mouth diet. The 
enrollee is currently confused, combative, and has mitts on for protection. The enrollee appears to be making 
progress and can continue current hospitalization until he can 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 the LTACH services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service August 3, 2022. 
 
You asked the Plan to pay for code 99285. You say that this claim should not have been down-coded. The Plan 
denied your request. The Plan says code 99285 is not supported by the medical record. There was no 
immediate significant threat to life or hospital admission, so criteria for this code are not met. As a result, this 
claim was down-coded to code 99284. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. 
 We asked our coder 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 code 99285. Our reviewer says that code 99285 is not 
supported by the medical record. Our reviewer found the enrollee was evaluated in the emergency room 
following a syncopal episode. The documented history is not comprehensive. The physical examination is 
borderline comprehensive. The medical decision making is not of high complexity. The enrollee underwent a 
standard syncope evaluation. There is no evidence of immediate threat to life or function. As such, the billing 
of CPT 99285 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service August 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on May 
17, 2023, through June 1, 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 the pneumatic compression device (E0675) provided on May 17, 2023, through June 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
March 29, 2023, and billed with codes 87150, 87481, 87641, 87651, 87798, and 87801. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says per Local Coverage Article (LCA) A58917, this type of testing must be 
billed as a single unit of service with 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 urine polymerase chain reaction (PCR) panel provided on March 29, 2023, 
and billed with codes 87150, 87481, 87641, 87651, 87798, and 87801.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 4, 2023, to 
August 21, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that home health services must be billed with a correct type of 
bill. 
 
We reviewed the file and the Medicare rules. We find that the type of bill on the claim was submitted 
incorrectly. The type of bill on the claim is submitted as 0324. However, the documentation shows that this is 
the incorrect type of bill. This means the claim is not payable as billed. Based on this information, we find that 
the Medicare rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from August 4, 2023, to August 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluid circulating cold pad with pump (E0218) provided 
on May 17, 2023, through June 1, 2023. 
 
You asked the Plan to pay for the fluid circulating cold pad with pump. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the fluid circulating cold pad with pump (E0218) provided on May 17, 2023, through 
June 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Tempus xF testing. 
 
You asked the Plan to pre-approve the Tempus xF testing. You say that this test was medically necessary. The 
Plan denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of the Tempus xF testing have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Tempus xF testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cervical traction equipment (E0849) provided on July 2, 
2023. 
 
You asked the Plan to pay for cervical traction equipment. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The provided medical records do not discuss the item at issue. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for cervical traction equipment (E0849) provided on July 2, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
on April 18, 2023. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the enrollee meets the criteria for a moderate level of care, which is consistent with CPT 99284. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee presented to the 
emergency department with nausea, multiple episodes of emesis, and generalized weakness. The enrollee was 
diagnosed with biliary colic and discharged home. The history and exam were appropriate; however, the 
documentation does not support support a high level of medical decision making. 
 
We looked at this coder's review, the file, and Medicare rules. 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 emergency room services (procedure code 99285) rendered on April 18, 2023.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services for date of service July 5, 2023, to July 27, 
2023. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that a corrected claim is needed to continue appeal process. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan has denied this claim due to that a corrected claim is 
needed to continue appeal process. The documentation does not include an explanation of why a corrected 
claim is required. No other denial rationale was provided. The Plan did not substantiate their denial. Therefore, 
we decided that the Plan has to pay for the home health services for date of service July 5, 2023, to July 27, 
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 Group 1 very heavy-duty power operated vehicle 
(POV), patient weight capacity 451 to 600 pounds (K0802). 
 You asked the Plan to pre-approve a power operated vehicle. You say that you are appealing the denial of code 
K0802 rental. The enrollee needs the scooter to perform daily activities. The Plan denied your request. The 
Plan says does not meet Medicare criteria for a Very Heavy Duty POV.  
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
Medicare rules say that a Very Heavy Duty POV is covered for a beneficiary weighing 428  600 pounds. The 
file shows that the enrollee weighs 312 pounds and therefore does not meet the Medicare criteria for the 
requested POV. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Group 1 very heavy-duty power operated vehicle (POV), 
patient weight capacity 451 to 600 pounds (K0802).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 16, 2023, billed with 
procedure code 01942. 
 You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the items/services are not considered medically 
reasonable and necessary. 
 
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 billed service was not reported with a diagnosis that supports 
medical necessity. Based on this information, we decided that Medicare rules for coverage of the practitioner 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for practitioner 
services provided on May 16, 2023, billed with procedure code 01942.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 31238 for date of service June 5, 2023. 
 
You asked the Plan to pay for procedure code 31238. 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. 
 
In this case, the CPT Code Manual definition of code 31238 is nasal/sinus endoscopy, surgical; with control of 
nasal hemorrhage. 
 
We find that CPT code 31238 is not supported in the medical record. Specifically, no operative report was 
provided for this date of service. This means this code cannot be verified by the documentation. Based on this 
information, we decided that Medicare rules for coverage of procedure code 31238 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 31238 for date of service June 5, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82306 and 84153 for date of service March 
7, 2023. 
 
You asked the Plan to pay for procedure codes 82306 and 84153. 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. Medicare rules say that providers must report 
the actual number of units provided for each procedure code. Medicare rules say that, for lab services, the POS 
code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken 
by the laboratory directly. 
 
We find that 2 units of CPT code 82306 are not supported in the medical record. The medical record only 
supports 1 unit of CPT code 82306. Code 81453 was billed with the laboratory POS code. The records do not 
support that the sample was taken in a laboratory setting. Based on this information, we decided that Medicare 
rules for coverage of procedure codes 82306 and 84153 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 82306 and 84153 for date of service March 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 18, 2023, billed with 
procedure codes 99291 and 99053-FT. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid.  The Plan denied your request. The Plan says code 99053 is considered bundled and is not 
separately payable. Documentation does not support code 99291. 
 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 99291 and 99053-FT are not supported in the medical record. Specifically, the 
documentation did not include the actual date that the service was rendered. Code 99053 has a status indicator 
B and is not separately payable. Based on this information, we decided that Medicare rules for coverage of the 
practitioner services provided have not been met. Therefore, we decided that the Plan does not have to pay for 
practitioner services provided on June 18, 2023, billed with procedure codes 99291 and 99053-FT.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cala Trio nerve stimulation device (K1018). 
 
You asked the Plan to pre-approve the Cala Trio device. You say that you are appealing the decision to deny 
the CALA KIQ E-Stim (electrical stimulation) device. The Plan denied your request. The Plan says this device 
is unproven and not covered by Medicare. 
 
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. There are not enough studies on Cala Trio to show it is safe and 
effective. Based on this information, we decided that Medicare rules for coverage of the Cala Trio device. have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the Cala Trio nerve stimulation 
device (K1018).