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

 
We decided that the Plan does not have to pre-approve a group 1 heavy duty power operated vehicle with a 
patient weight capacity 301 to 450 pounds (K0801). 
 
You asked the Plan to pre-approve a group 1 heavy duty power operated vehicle. You say that you are 
homebound, confined to your room, and immobile without the use of a scooter. You also say that you need a 
scooter to function and be mobile, and your current weight is 291 pounds. The Plan denied your request. The 
Plan says you were approved for another scooter on February 10, 2023 which has a weight limit of up to 300 
pounds. The Plan also says that this request cannot be approved at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that a POV is covered if the beneficiarys weight is 
less than or equal to the weight capacity of the POV that is provided and greater than or equal to 95% of the 
weight capacity of the next lower weight class POV. 
 
 
 
 
 We looked at the file and Medicare rules. The record shows that during your POV evaluation on February 24, 
2023, your weight was 265 pounds. You also stated that you were above or around 280 pounds as of April 4, 
2023. Based on this information, we decided that Medicare rules for coverage of a group 1 heavy duty power 
operated vehicle have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 1 
heavy duty power operated vehicle with a patient weight capacity 301 to 450 pounds (K0801).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1843). 
 
You asked the Plan to pre-approve the brace. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show recent injury, recent surgery, or knee instability. 
 
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 brace. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that on March 29, 2023, the enrollee was evaluated for knee pain. No specific injury was reported. Ligamentously, the enrollee appeared to be stable. There has been no recent surgery, or instability documented 
on examination. 
 
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 brace have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a knee orthosis (L1843).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 4, 2023. 
 
You asked the Plan to pay for the evaluation and management service. You say that you have been seeing this 
provider for years. You say that you feel it would be difficult to find another provider to prescribe bioidentical 
hormones compounded specifically for your needs. You also say that you thought Medicare provided coverage 
for retiree enrollees. The Plan denied your request. The Plan says the provider has opted out of Medicare. The 
Plan also says payment cannot be made for services performed by a provider that has opted out of Medicare. 
 
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 on January 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Liquid CDx (0239U) provided on June 
13, 2022. 
 
You asked the Plan to pay for the FoundationOne Liquid CDx . You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the FoundationOne Liquid CDx have 
been met. Specifically, no medical records or literature was provided to support the service at issue. Only lab 
results were submitted. No office or clinical notes were provided to support medical necessity of this service. 
Therefore, we decided that the Plan does not have to pay for the FoundationOne Liquid CDx (0239U) provided 
on June 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0037U provided on August 3, 2022. 
 
You asked the Plan to pay for procedure code 0037U. You say that you would like the Plan to reconsider their 
denial of payment. 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 procedure code 0037U 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 0037U 
provided on August 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service May 25, 
2022.  
 
You asked the Plan to pay for procedure code 0003A. You say that this service 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 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 0003A 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 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service May 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found provided records document that the home ventilator is being requested for use in a volume targeted pressure support mode which could be provided by a 
BiPAP device with average volume assured pressure support (AVAPS) and a back-up rate. Provided records do 
not document trial and failure of 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on July 21, 2022, billed with code 
71045-26. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 24, 2022. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the imaging services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for imaging services provided on July 21, 2022, 
billed with code 71045-26.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service June 8, 
2022.  
 
You asked the Plan to pay for procedure code 0003A. You say that this claim 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 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 0003A 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 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service June 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 67840 billed for date of service January 24, 
2023. 
 You asked the Plan to pay for procedure code 67840. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 67840 is bundled into payment for code 67800. 
 
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 67840 
is a column II code to column I code 67800. 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 67840 billed for date of service January 24, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 26, 2023. 
 
You asked the Plan to pay for the evaluation and management service. You say that you have been seeing this 
provider for years. You say that you feel it would be difficult to find another provider to prescribe bioidentical 
hormones compounded specifically for your needs. You also say that you thought Medicare provided coverage 
for retiree enrollees. The Plan denied your request. The Plan says the provider has opted out of Medicare. The 
Plan also says payment cannot be made for services performed by a provider that has opted out of Medicare. 
 
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 on January 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion supplies not used with external infusion pump 
(A4223) provided on February 6, 2023. 
 
You asked the Plan to pay for the infusion supplies. The Plan denied your request. The Plan says the service 
billed is statutorily excluded from coverage under the Medicare program. 
 
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 code A4223 is not supported in the medical record. Specifically, this code is not supported as 
it has a status indicator of X, meaning the code is statutorily excluded. Based on this information, we decided 
that Medicare rules for coverage of the infusion supplies have not been met. Therefore, we decided that the 
Plan does not have to pay for the infusion supplies not used with external infusion pump (A4223) provided on 
February 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that a ventilator will prevent future hospitalizations. The 
Plan denied your request. The Plan says the enrollee's needs could be met by a bilevel positive airway pressure 
(BiPAP) device. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
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 exceeds the established 
defining criteria for an appropriate Lon Term Acute Care Hospital.  The Plan denied your request. The Plan 
says the enrollee is receiving the appropriate inpatient care and is currently unstable for 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 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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: 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 does not meet all the required Medicare 
criteria for admission to an Inpatient Rehabilitation Facility. Services needed may be provided safely in a lower 
level of care. The Plan denied your request. The Plan says the enrollee does not meet all the required Medicare 
criteria for admission to an Inpatient Rehabilitation Facility. 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 
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. Our physician reviewer found the 
enrollee needs interdisciplinary care team approach when it comes to nursing and therapy. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 
19, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable.  
 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network chest x-ray provided on 
December 27, 2022. 
 
You asked the Plan to waive the copayment for an in-network chest x-ray. You say that you already paid for 
the office visit, you should not have to pay for the x-rays as well. If extra views cost more, they should tell you. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for medicare-covered standard Xray service. 
 
You have been asked to pay a $15 copayment for an in-network chest x-ray. This item/service falls within the 
medicare-covered standard Xray service benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. You had two x-rays resulting in a $30 total copayment ($15 x 2 = $30). 
Therefore, we decided that the Plan does not have to waive the copayment for an in-network chest x-ray 
provided on December 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 29, 2022, 
to October 28, 2022. 
 You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. 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 September 29, 2022. The NOA was not received by the Plan until 
November 3, 2022. 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 provided from September 29, 2022, to October 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on October 11, 2022, to 
October 13, 2022, billed with principal diagnosis code A41.9, described as Sepsis, unspecified organism and 
secondary diagnosis code R65.20, described as Severe sepsis without septic shock.  
 
You asked the Plan to pay for inpatient hospital care provided. You say that the claim was billed correctly and 
should be paid The Plan denied your request. The Plan says documentation does not support the billed codes. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of inpatient hospital care provided have 
been met. Specifically, no medical records for the inpatient hospital care were provided for review. Therefore, 
we decided that the Plan does not have to pay for inpatient hospital care provided on October 11, 2022, to 
October 13, 2022, billed with principal diagnosis code A41.9, described as Sepsis, unspecified organism and 
secondary diagnosis code R65.20, described as Severe sepsis without septic shock.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service May 4, 
2022.  
 
You asked the Plan to pay for procedure code 0003A. You say that this claim 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 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 0003A 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 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service May 4, 2022.