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

 
We decided that the Plan has to pre-approve a Koya Dayspring System pneumatic compression device (K1024, 
K1033). 
 
You asked the Plan to pre-approve intermittent limb compression device. You say that you disagree with the 
denial. The Plan denied your request. The Plan says that the current peer-reviewed medical literature does not 
support that the requested Dayspring non-pneumatic compression device has been shown in controlled studies 
in a Medicare-approved journal to result in long-term health benefits for the treatment of lymphedema. 
 
The Plan must follow Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers.  
 
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 intermittent limb compression device. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee meets criteria as listed. The enrollee has a diagnosis of 
lymphedema as defined, she has documented marked hyperkeratosis with hyperplasia and hyperpigmentation, 
and she has had refractory disease for 2 years of drainage 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 intermittent limb compression device have been met. Therefore, we decided that 
the Plan has to pre-approve a Koya Dayspring System pneumatic compression device (K1024, K1033).  
 
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 radiation treatment management, 5 treatments provided on 
April 3, 2023. 
 
You asked the Plan to pay for the radiation treatment management, 5 treatments. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the provider must indicate the number of 
refractions for consideration and the refraction dates in the claim notes 
 
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 radiation treatment management, 5 
treatments have been met. Therefore, we decided that the Plan does not have to pay for radiation treatment 
management, 5 treatments provided on April 3, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 20680 rendered on April 7, 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 that Current Procedural Terminology (CPT) code 20680-RT-59 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 20680 is "Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate)." 
 
We asked our 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 services. Our reviewer says that the services at issue 
in this case were supported by the medical records. Our reviewer found that the procedure details cite the 3rd 
digit of a prior hammertoe implant was 12 extracted from the joint. This was after the osteotomy was performed 
at the third metatarsal head and extended out proximal medial and proximal lateral aspects of the 3rd 
metatarsal. Therefore, the records do support that CPT 20680: removal of implant, deep (e.g., buried wire, pin, 
screw, metal band, nail, rod, or plate) as a distinct and independent procedure from CPT 28308: osteotomy, 
with or without lengthening, shortening or angular correction, metatarsal; other than fist metatarsal, each. 
 
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 20680 rendered on April 7, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 17, 2022, to 
November 11, 2022. 
 You asked the Plan to pay for the home health services. You say that this claim should be reprocessed for 
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 July 15, 2022. The NOA was not received by the Plan until December 22, 
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 home health services provided 
from October 17, 2022, to November 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthosis (L4361) provided on March 30, 2023. 
 
You asked the Plan to pay for the orthosis. You say that this equipment was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claim lines billed without a KX, GA or GZ 
modifier will be rejected as missing information. 
 
We looked at the file and Medicare rules. The claim did not include a required modifier. Based on this 
information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we 
decided that the Plan does not have to pay for an orthosis (L4361) provided on March 30, 2023.
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 it is medically necessary. The Plan denied your 
request. The Plan says you do not meet the requirements for approval. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
encephalopathy, hyponatremia and hypokalemia and was transferred to skilled nursing on July 24, 2023. 
Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. 
 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77061 and G0279 billed for date of service 
April 19, 2022. 
 
You asked the Plan to pay for procedure codes 77061 and G0279. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
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 77061 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77061 is not valid for Medicare purposes. Additionally, we have confirmed that code G0279 is 
an add-on code and has not been billed with either 77065 or 77066. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 77061 and G0279 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 77061 and G0279 billed for date of service April 19, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 0018U and 0245U billed for July 14, 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 procedure codes 0018U and 0245U are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 0018U is oncology (thyroid), microRNA profiling by 
RT-PCR of 10 microRNA sequences, utilizing fine needle aspirate, algorithm reported as a positive or negative 
result for moderate to high risk of malignancy. The definition of code 0245U is ncology (thyroid), mutation 
analysis of 10 genes and 37 RNA fusions and expression of 4 mRNA markers using next-generation 
sequencing, fine needle aspirate, report includes associated risk of malignancy expressed as a percentage. 
 
We find that CPT codes 0018U and 0245U are not supported in the medical record. Specifically, the records do not support that a specimen was collected for the billed date of service. Based on this information, we decided 
that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 0018U and 0245U billed for July 14, 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 you are requesting an expedited reconsideration as 
the enrollee currently meets full IRF criteria. The Plan denied your request. The Plan says the enrollee does not 
meet Medicare guidelines for services in an IRF.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for April 2, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was billed with the incorrect place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The file shows that the claim was billed with POS code 21 for 
inpatient; however, the enrollee was under outpatient status for the billed date of service. Therefore, we decided 
that the Plan does not have to pay for procedure code 99223 billed for April 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the device was prescribed to help manage 
the enrollee's complicated respiratory needs at home. The Plan denied your request. The Plan says the request 
for a home mechanical ventilator set in assist control mode with very low tidal volumes and low positive end-
expiratory pressure that could be delivered by BiPAP is not covered. 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a progressive lung 
disease, usual interstitial pneumonia (UIP), interstitial lung disease (ILD), and will ultimately require 
transplantation or succumb to his disease process. The use of BIPAP to assist in ventilation is reasonable and a 
rational approach to this deadly disease process. Without transplantation, the enrollee will expire and BIPAP 
with or without average volume-assured pressure support (AVAPS) may slow his demise until transplantation 
can be determined. The enrollee does not have supportive documentation for home ventilation. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service March 4, 
2023.  
 You asked the Plan to pay for procedure code 86077. You say that these services were necessary and are 
supported in the medical record. 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 86077 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 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service March 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit (99348) provided on January 23, 
2023. 
 
You asked the Plan to pay for a home or residence visit. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a home or residence visit have not been met. Specifically, the services at issue have been billed 
with POS 33, indicating that services were rendered in a custodial-care facility. This is not a covered place of 
service. Therefore, we decided that the Plan does not have to pay for a home or residence visit (99348) 
provided on January 23, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the services are medically necessary to 
determine which type of dementia the enrollee has. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee was noted to have a history of 
a cognitive impairment. However, the records did not suggest a diagnosis of either AD or FTD. In this setting, 
the base criteria for coverage would not be considered to have been met. Therefore, the request does not meet 
the NCD criteria for coverage.  
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on August 31, 2022. 
 
You asked the Plan to pay for the home visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit provided 
on August 31, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve bioimpedance spectroscopy services. 
 
You asked the Plan to pre-approve the services. You say that the enrollee is at high risk for developing 
lymphedema, and use of the requested device is medically necessary. The Plan denied your request. The Plan 
says that additional research and development is needed before the method can be accepted for routine clinical 
use. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that bioimpedance spectroscopy has been included in updated clinical practice guidelines for breast 
cancer lymphedema assessment and is Food and Drug Administration (FDA) approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve bioimpedance spectroscopy services.  
 
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.