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

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump billed with code 
E0217 for dates of service October 1, 2022, to October 18, 2022. 
 
You asked the Plan to pay for code E0217. You say that this item was medically necessary, and the literature 
shows the efficacy of this item. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that water circulating heat pads with pumps (E0217) 
are not covered.  The item in dispute in this case is a water circulating heat pads with pumps (E0217), so the 
Plan cannot be required to pay for this item. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code E0217 have not been met. Therefore, we decided that the Plan does not have to pay for the 
water circulating heat pad with pump billed with code E0217 for dates of service October 1, 2022, to October 
18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam billed with code 92002 for September 15, 
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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that pre-operative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. Procedure code 92002 was related to and billed on the same day as 
major surgical procedure billed with code 67400. Payment for code 92002 is included in the global surgical 
payment for code 67400. Therefore, we decided that the Plan does not have to pay for the eye exam billed with 
code 92002 for September 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E0431). 
 
You asked the Plan to pre-approve a portable oxygen concentrator . You say that the item is medically 
necessary. The Plan denied your request. The Plan says this item is not covered for cluster heachaces, 
 
The Plan must follow Medicare rules. Medicare rules say that a portable oxygen system is covered if the 
enrollee is mobile within the home for Groups I and II, and the qualifying blood gas study was performed while 
at rest (awake) or during exercise.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a portable oxygen concentrator  have not been met. Specifically, cluster headaches is categorized 
as group III and this item is not covered for group III. Therefore, we decided that the Plan does not have to pre-
approve a portable oxygen concentrator (E0431).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (81201, 81292, 81298) provided on October 20, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes 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 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 use of codes 81201, 
81292, and 81298, is not supported by the records provided. Our reviewer found that after review of the 
laboratory report, results were not found for the billed procedures, and therefore the billed codes cannot be 
verified. 
 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 the services (81201, 81292, 81298) provided on October 20, 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 the services are medically necessary. The Plan 
denied your request. The Plan says your needs can be met at an alternate level of care.  
 
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 that you do not require treatment by multiple therapies. While the medical record 
supports a need for physical 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the wrist hand orthosis (L3916) and thoracic-lumbar-sacral 
orthosis (L0457) provided January 12, 2023. 
 
You asked the Plan to pay for the orthoses. You say that the services were provided based on the physician's 
orders.  The Plan denied your request. The Plan says the DME is not supported by the referring physician 
exam. 
 
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 pay for the orthoses. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, the documentation doesnt indicate the enrollee has had a new injury or any 
specific problems to the spine or related soft tissue. There is no indication that the enrollee has had any surgical 
procedure. There is no clear indication that the enrollee required a thoracic-lumbar-sacral orthosis. There is no 
clear documentation available for review that supports the enrollee has significant hand or wrist pain or any 
abnormal physical findings that would necessitate treatment with an orthosis. The requested orthoses do not 
appear appropriate to the enrollees medical needs and condition. 
 
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 orthoses have not been met. Therefore, we decided that the Plan does not 
have to pay for  the wrist hand orthosis (L3916) and thoracic-lumbar-sacral orthosis (L0457) provided January 
12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the back post push handles (K0108). 
 
You asked the Plan to pre-approve the back post push handles . You say that the item should be covered. The 
Plan denied your request. The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the back post push handles (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99458 billed for date of service March 30, 
2023.   
You asked the Plan to pay for procedure code 99458. 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 99458 is 3. The MAI value for this code is 3. You billed 4 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 99458 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99458 billed for date of service March 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 5, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0856) and additional 
items and accessories (codes E0953, E0955, E1002, E1012, E1020, E1028, E2311, E2361, E2607, and E2620). 
 
  You asked the Plan to pre-approve a group 3 power wheelchair and additional items and accessories. You say 
that you would like the K0856 base, and all recommended components needed to meet the enrollee's current 
medical, mobility, and functional needs to be reconsidered. The Plan denied your request. The Plan says the 
enrollee does not have medical need for single power option included with K0856 group 3 power wheelchair. 
The Plan also says E2311 is not medically needed as there is no need to control two power options through the 
joystick. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with power seating 
system, tilt only, may be covered if certain criteria listed in the Medicare rules section of this letter 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 a group 3 power wheelchair and 
additional items and accessories. Our reviewer says that the enrollee does not meet the coverage criteria for a 
group 3 power wheelchair. Our physician reviewer found the enrollee has a leg amputation and transverse 
myelitis. The enrollee uses a power wheelchair currently, lives alone and is independent with activities of daily 
living. Our reviewer found that the enrollee transfers independently. The enrollee does not have skin 
breakdown, high risk for skin breakdown, use catheter, or have spasticity. Our physician reviewer also found 
that the enrollee does not require alternative means of power drive control.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 3 power wheelchair and additional items and accessories have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0856) 
and additional items and accessories (codes E0953, E0955, E1002, E1012, E1020, E1028, E2311, E2361, 
E2607, and E2620).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in Intelligent Volume Assured 
Pressure Support (iVAPS) mode with Auto-EPAP (AE) that could be delivered by bilevel positive airway 
pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that the 
provided records document that the home ventilator is being requested for use in average volume assured 
pressure support (AVAPS) mode with auto-EPAP (AE) which could be provided by a bilevel positive airway 
pressure (BiPAP) device with AVAPS and a back-up rate. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home mechanical ventilator.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on February 20, 2022, to February 
27, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says that documentation 
does not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code J96.21, described as 
Acute and chronic respiratory failure with hypoxia. We asked our physician reviewer to carefully review the 
case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to 
pay for the inpatient hospital services at the DRG originally billed. Our reviewer says that documentation does 
support the billed code. Our physician reviewer found that the enrollee has chronic respiratory failure due to 
chronic obstructive pulmonary disease and had acute exacerbation due to pneumonia. She thus meets clinical 
criteria and documentation for J96.21. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on February 20, 2022, to February 27, 2022, at the Diagnosis Related Group (DRG) 
originally billed.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total parenteral nutrition. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says enteral nutrition has not been ruled out. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the review indicates that there was no documentation indicating that the treating practitioner 
documented that enteral nutrition had been considered and ruled out, tried and been found ineffective, or that 
enteral nutrition exacerbates gastrointestinal tract dysfunction. The review has determined that the enrollee 
does not meet the criteria for this request.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve total parenteral nutrition.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on January 9, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for a home visit. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a home visit provided on January 9, 2023, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for 
date of service July 13, 2022. 
 You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, and 88381. The Plan denied your 
request. The Plan says these codes are included in the facility payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88360, and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360, and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for date of service July 13, 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 the enrollee is needing daily physician oversight for 
medical management while in intensive rehabilitation setting with active comorbidities. The Plan denied your 
request. The Plan says the enrollee's records show that it is not reasonable to expect to be able to safely 
participate in, or fully benefit from, the intensity of services of an IRF. Services needed may be provided safely 
in a lower level of care. 
 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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.