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

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on April 4, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on April 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on March 27, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on March 27, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 36556 rendered on March 14, 2022. 
 
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 that the records do not support the services 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 36556 is "Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older." 
 
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 supported by the medical records. Our reviewer found that the documentation supports that the 
services in question were rendered and appropriately coded.  There is satisfactory documentation that a central 
line was placed in the internal jugular vein. There is satisfactory documentation that the triple lumen line was 
placed centrally. As most central lines placed in the emergency department are not placed under fluoroscopic 
guidance, exact location of the tip cannot be documented, and it is not reasonable to require this information to 
justify billing. Nevertheless, in this case, the documents provided do include the subsequent chest x-ray report 
confirming central placement with the tip at the cavo-atrial junction. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure code 36556 rendered on March 14, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93976-26 billed for date of service February 
7, 2023.  
 
You asked the Plan to pay for procedure code 93976-26. You say that the claim is billed correctly and should 
be paid. 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 93976-26 is 1. The MAI value for this code is 3. You billed 2 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 93976-26 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 93976-26 billed for date of service February 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service March 26, 
2023, to April 22, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service March 26, 2023, to April 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 21, 2022, billed 
with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have billed the services at issue 
correctly. 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 
November 21, 2022, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 
81328, 81335 and 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, 87798, and 87801, billed for 
date of service February 7, 2023. 
 You asked the Plan to pay for procedure codes 87481, 87653, 87798, and 87801. The Plan denied your request. 
The Plan says the claim is not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 87481, 
87653, and 87798 are column II codes to column I code 87801. 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. 
 
We find that CPT code 87801 is not supported in the medical record. Specifically, the records provided do not  
confirm the multiple organisms represented by code 87801. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87481, 87653, 87798, and 87801 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87481, 87653, 87798, and 87801, 
billed for date of service February 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.  
You asked the Plan to pre-approve the CGM and supplies. You say that unless your blood sugar is continually 
monitored your kidneys will continue to deteriorate. You also say that due to this, very accurate and consistent 
monitoring of your blood sugar level is crucial. The Plan denied your request. The Plan says you do not meet 
the coverage criteria for the CGM and supplies. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM and supplies. Our reviewer 
says that the CMG and supplies are not medically necessary. Our physician reviewer found coverage criteria 
for CGM require either insulin use or low blood glucose sugar. You are taking Jardiance as of June 2023 and 
this does not cause low blood glucose sugar. Although the CGM might help you gain an understanding of the 
impact of different foods on blood glucose sugar levels, criteria for CGM coverage provided are not met. It is 
also not clear why a finger stick glucometer would not suffice at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CGM and supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guidance UTI panel (87500, 87511, 87640, 87653, 
87798, 87801) provided March 3, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you provided the services in good faith that 
you would be reimbursed. The Plan denied your request. The Plan says the requested testing exceeds the 
patient's medical needs. and is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found it is unclear as there are no medical notes to justify the testing. For instance, if the 
enrollee was asymptomatic then it would not be needed. Further, it is unclear why this was completed over 
typical culture.  
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the Guidance UTI panel (87500, 87511, 87640, 87653, 87798, 87801) provided March 
3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by an opted-out provider on March 
7, 2023. 
 
You asked the Plan to pay for the office visit. You say that the claim should be billed under the enrollee's out-
of-network benefits. The Plan denied your request. The Plan says that the original decision to deny payment 
was correct. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
 
  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office 
visit provided by an opted-out provider on March 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies coded as T4522, T4537 and 
T4541. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies coded as 
T4522, T4537 and T4541.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occupational therapy (OT) services to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee is currently out of the service 
area and requires therapy following surgery. The Plan denied your request. The Plan says network providers 
are available to render necessary care. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 therapy services. Our reviewer says that the requested services are not 
considered urgent of emergent. Our physician reviewer found the member has had elective surgery by an in-
network provider and then traveled voluntarily to another city. There is no documentation that supports the 
condition of the surgery or of the requested therapy was of an urgent or emergent need. There is no medical 
necessity to proceed with the requested therapy from an out-of-network provider. 
 
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 therapy services have not been met.  
 
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 the therapy services. Therefore, we decided that the 
Plan does not have to pre-approve occupational therapy (OT) services to be provided by an out-of-network 
(OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on July 20, 2022, to 
August 18, 2022. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is July 20, 2022. The NOA was not received by the Plan until April 5, 2023. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for the home health services rendered on 
July 20, 2022, to August 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0427, A0425) provided on January 27, 
2023. 
 
You asked the Plan to pay for ambulance services. You say that these services were necessary and were 
reported with appropriate codes. The Plan denied your request. The Plan says this claim was submitted with 
two incompatible diagnoses. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that when a diagnosis code has an Excludes1 note, it is inappropriate to report the noted condition 
together with the condition with the note. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulance services have not been met. Specifically, this claim was submitted with diagnosis codes 
R40.20 and E10.65. However, R40 codes have an Excludes1 note with codes in the E08-E13 range. This means 
it is generally inappropriate to report these codes together. Therefore, we decided that the Plan does not have to 
pay for ambulance services (A0427, A0425) provided on January 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 for date of service 
April 13, 2023. 
 
You asked the Plan to pay for procedure codes 96365, 96366, and 96521. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 96365, 96366, and 96521 are not supported in the medical record. Specifically, the 
documentation shows that Outpatient Intravenous Insulin Treatment (OIVIT) either pulsatile or continuous, 
by any means, guided by the results of measurements for: respiratory quotient; and/or, urine urea nitrogen 
(UUN); and/or, arterial, venous or capillary glucose; and/or potassium concentration was performed. This 
means there is a more appropriate code to be billed and codes 96365 and 96366 are not supported. The medical 
records submitted include an order to perform refilling and maintenance of portable pump; however, the records indicate that Outpatient Intravenous Insulin Treatment (OIVIT) was performed and doesnt include a 
procedure report for pump maintenance refill. This means code 96521 cannot be verified. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 96365, 96366, and 96521 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 96365, 96366, and 
96521 for date of service April 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96374 and 96375 billed for date of service 
February 3, 2022. 
 You asked the Plan to pay for procedure codes 96374 and 96375. The Plan denied your request. The Plan says 
payment for codes 96374 and 96375 is bundled into payment for code 64483. 
 
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 codes 
96374 and 96375 are column II codes to column I code 64483. 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 codes 96374 
and 96375 billed for date of service February 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11981 rendered on April 11, 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 records do not support the services 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 11981 is "Insertion, drug-delivery implant (ie, 
bioresorbable, biodegradable, non-biodegradable)." 
 
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 CPT code 11981 is not supported. 
The record does not state that a drug delivery implant was placed during this encounter.  
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 procedure code 11981 rendered on April 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on March 20, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim for this 
molecular pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing provided on March 20, 2023.