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 (E0675) provided from 
August 19, 2022 to September 9, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this request is medically 
necessary based on the medical literature and the efficacy of the treatment rendered. The Plan denied your 
request. The Plan says this denial was appropriate. 
 
The Plan follows Medicare rules. The rules state 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 from August 19, 2022 to September 9, 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 April 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 April 25, 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 meets the criteria for inpatient 
rehabilitation admission. The Plan denied your request. The Plan says the enrollee is without complex 
rehabilitation needs. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on October 19, 2022. 
 
You asked the Plan to pay for the physician's services. You say that you have been seeing this provider for 
years and this provider gives you a great level of care. The Plan denied your request. The Plan says you got the 
services from a provider who chose not to receive Medicare funds. 
 
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 
physician's services provided on October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service December 28, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says code 99153 is not payable in the facility 
setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service December 28, 2022, 
billed with code 99153.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from January 7, 2023, to 
January 23, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that this psychotherapy will be beneficial to your 
health and well-being. The Plan denied your request. The Plan says this provider type is not eligible to enroll in 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from 
January 7, 2023, to January 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve panniculectomy and rhytidectomy. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request is within the standard of care, but is considered not medically necessary, and 
thus cosmetic in this case. 
 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 in this case, the record indicates that the enrollee has has weight loss following bariatric 
surgery.  The record provided does not indicate that the requested procedures are to correct congenital defects, 
developmental abnormalities, trauma, infections, tumors, or disease nor does it establish the presence 
of inability to walk normally, chronic pain, ulceration created by the abdominal skin fold, or intertrigal 
dermatitis that has been present for at least three months and are refractory to usual standard medical therapy. 
The record provided does not indicate functional impairment as a result of a disease state. The elements of the 
coverage criteria are not satisfied.  
 
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 panniculectomy and rhytidectomy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection (96372), unlisted special service (99199), and 
vitamin b-12 cyanocobalamin (J3420) provided on May 12, 2022. 
 
You asked the Plan to pay for the injection services. 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 
injection (96372), unlisted special service (99199), and vitamin b-12 cyanocobalamin (J3420) provided on May 
12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cleaning machine for your CPAP (continuous positive 
airway pressure) device. 
 
You asked the Plan to pre-approve a cleaning machine. You say that you have difficulties cleaning your CPAP 
machine. You also say that you would like the cleaning machine to be approved because it will help you a lot. 
The Plan denied your request. The Plan says the cleaning machine is not primarily used for a medical purpose, 
does not treat illness or injury, and is not reasonable and medically necessary by Medicare definitions. 
 
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 a cleaning machine for your CPAP (continuous positive 
airway pressure) device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) and hospital clinic visit (G0463) 
provided on December 24, 2022. 
 
You asked the Plan to pay for the outpatient service. You say that you were having severe pain in your mouth 
and jaw area. You say that by the time you decided to go and see someone, there were no dental offices open 
due to the holiday. You say that you were hoping to get a prescription for your pain. You also say that  The 
Plan denied your request. The Plan says the claim denied correctly. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Though the Plan offers a dental benefit in excess of Medicare coverage, the services are not 
among those covered under this benefit.  Therefore, we decided that the Plan does not have to pay for the office 
visit (99203) and hospital clinic visit (G0463) provided on December 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig and sales tax purchased on February 10, 2023. 
 
You asked the Plan to pay for the wig and sales tax. You say that you were told the wig would be covered. The 
Plan denied your request. The Plan says wigs are a non-covered service. 
 
 
 Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. The rules also say that Medicare does not make 
separate payment for sales tax. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wig and sales tax 
purchased on February 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87631, 94761 and 99072 billed for date of 
service November 21, 2022. 
 
You asked the Plan to pay for procedure codes 87631, 94761 and 99072. You say that you have correctly billed 
the services at issue. The Plan denied your request. The Plan says the claim for the molecular pathology testing 
denoted by code 876931 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 denoted 
by code 87631, 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. The rules also say that 
providers must report services correctly. Providers must report services with the appropriate procedure code. 
 
We looked at the file and Medicare rules. Review of the claim for procedure code 87631 does not show that the 
required unique identifier was reported. Based on this information, we decided that Medicare rules for coverage 
of procedure code 87631 have not been met. We also find that procedure code 94761 has a status indicator of T 
on the Physician Fee Schedule. The case record documents that other services billed on the same date by the 
same provider have been paid for by the Plan. This means that procedure code 94761 is not separately payable. 
Finally, we find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This 
means that procedure code 99072 is not separately payable. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99072 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 87631, 94761 and 99072 billed for date of service November 21, 
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 could walk with a rollator, cane before, 
and now is not walking. The Plan denied your request. The Plan says the enrollee does not meet all of the 
requirements. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit tie-down system (K0108) for a manual 
wheelchair. 
 
You asked the Plan to pre-approve a transit tie-down system. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested item is not a covered 
benefit. 
 
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. Therefore, we 
decided that the Plan does not have to pre-approve a transit tie-down system (K0108) for a manual wheelchair.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service January 6, 
2023. 
 You asked the Plan to pay for procedure code 71045. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for code 
36556. 
 
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 71045 
is a column II code to column I code 36556. 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 71045 billed for date of service January 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to ESRD provided on 
December 19, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you have correctly billed the 
services at issue. 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 ESRD provided on December 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S0189 billed for date of service November 
18, 2022. 
 
You asked the Plan to pay for procedure code S0189. 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 S0189 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S0189 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S0189 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S0189 billed for date of service November 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve detachable armrests (E0973) and repairs (K0739) to be 
rendered by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the detachable armrests and repairs. The Plan denied your request. The Plan 
says the requested provider is OON with your plan. The Plan also says they have confirmed there is an in-
network provider who is able to provide removable adjustable arms and perform repairs. 
 
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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve 
detachable armrests (E0973) and repairs (K0739) to be rendered by an out-of-network (OON) provider.
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 March 5, 
2022.  
 You asked the Plan to pay for procedure code 0003A. You say that this is a covered service and the 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 March 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit (99334) provided on October 3, 2022, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient service. You say that the service was rendered to the enrollee in 
good faith. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider 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 the domiciliary visit (99334) provided on October 
3, 2022, by an out-of-network (OON) provider.