Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mobile X-Ray services provided on March 22, 2022. 
 
You asked the Plan to pay for mobile X-Ray. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this claim was billed with the incorrect Place of Service (POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that if a mobile unit serves an entity for which 
another POS code exists, the provider should use the POS code for that entity.  
 
We looked at the file and Medicare rules. This mobile X-Ray was performed in a skilled nursing facility (SNF); 
therefore, the POS code 11 indicating a physicians office is not appropriate for this claim. Based on this 
information, we decided that Medicare rules for coverage of mobile X-Ray have not been met. Therefore, we 
decided that the Plan does not have to pay for mobile X-Ray services provided on March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for HBO therapy provided on July 28, 2022.  
 
You asked the Plan to pay for the HBO therapy. You say that HBO therapy was medically necessary. The Plan 
denied your request. The Plan says HBO therapy does not meet the Medicare NCD coverage criteria.  
 
The Plan follows Medicare rules. 
 
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 HBO therapy. Our reviewer says that the 
requested HBO therapy is not considered medically necessary in this case. Our physician reviewer found that 
the enrollee has a diagnosis of traumatic brain injury. The record sent by his provider indicates he had a motor 
vehicle accident in 2008 and hyperbaric oxygen therapy in the past helped  his cognitive abilities. The review 
has determined that  the requested HBO therapy does not meet the Medicare NCD coverage criteria. 
 
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 HBO therapy have not been met. Therefore, we decided that the Plan does 
not have to pay for HBO therapy provided on July 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer System implantable pulse generator (IPG). 
 
You asked the Plan to pre-approve the device. You say that the requested device is necessary to improved 
cardiac functional capacity and quality of life. You also say that this is necessary for symptom management. 
The Plan denied your request. The Plan says the requested device 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 pre-approve the device. Our reviewer says that the 
requested device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found while the clinical studies led to approval by the Food and Drug Administration (FDA) in 2019, cardiac 
contractility modulation (CCM) remains the subject of multiple studies examining long-term efficacy, as well 
as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. Therefore, the reviewer found 
that the requested device is not medically reasonable or necessary. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an Optimizer System implantable pulse generator (IPG).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Trazimera. 
 
You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says that Trazimera is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug. Our reviewer says that 
Trazimera is medically necessary. Our physician reviewer found that the use of Trazimera is FDA-approved as 
adjuvant therapy for breast cancer with human epidermal growth factor receptor 2 (HER2) overexpressing node 
negative breast cancer with one high-risk feature, which in this case is grade 3. The requested drug is also 
supported by one of the major drug compendia and by clinical research. 
 
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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
Trazimera.  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the molecular laboratory testing (code 87631) provided on December 
27, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that your claim did not 
include the required unique identifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
The record shows that the Plan has denied this service using rules that are only applicable to Molecular 
Diagnostics (MolDX) jurisdictions. These services were not provided in a jurisdiction in which MolDx rules 
apply. Therefore, we decided that the Plan has to pay for the molecular laboratory testing (code 87631) 
provided on December 27, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department and related services provided on 
October 1, 2022. 
 
You asked the Plan to pay for the emergency department and related services. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the services billed are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the emergency department and related 
services provided on October 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9348 billed for date of service December 
24, 2022, to December 30, 2022. 
 
You asked the Plan to pay for procedure code S9348. You say that this claim should be processed as in-
network. 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 S9348 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9348 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9348 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9348 billed for date of service December 24, 2022, to December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service October 28, 
2022.  
 You asked the Plan to pay for procedure code 99291. You say that the enrollee had multiple exams on this date 
of service. 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 99291 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 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service October 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 23, 2021, to 
August 25, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.9, described as Sepsis, 
unspecified organism, and secondary diagnosis code R65.20, described as Severe sepsis without septic shock. 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the DRG 
originally billed. Our reviewer says that documentation does not support the billed codes. Our physician 
reviewer found that the enrollee presented with abdominal pain in the setting of known cancer, recent 
cholecystitis, recent paracentesis and failure to thrive. She was found to have a peritoneal infection and 
determined to be a candidate for Hospice. While the enrollee was chronically ill, there is no evidence that the 
enrollee had acute sepsis. As such, the billing of A41.9 and R65.20 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 23, 2021, to August 25, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
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 would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says  the inpatient rehabilitation facility (IRF) 
services you are requesting 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 enrollee does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump, any type 
(E0218). 
 
You asked the Plan to pre-approve a fluid circulating cold pad with pump. You say that you will be having 
surgery and you need this cold pad wit pump so that you will not get blood clots. The Plan denied your request. 
The Plan says the requested fluid circulating cold pad with pump is denied as not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a fluid circulating cold pad with pump, any type (E0218).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued coverage for home ventilator, any type, used 
with non-invasive interface (E0466). 
 
You asked the Plan to pre-approve the Life2000 System noninvasive ventilator. You say that approving the 
authorization for this life saving device, will allow this enrollee to maintain activities of daily living and 
decreasing the frequency of exacerbations and hospitalizations. The Plan denied your request. The Plan says 
under Medicare, the request is not medically necessary. 
 
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 the Life2000 System noninvasive 
ventilator. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the Life2000 system is not medically necessary. This 
enrollee has severe COPD and has had a Life2000 device since May 2022. The Life2000 system is not a true 
ventilator because it is not capable of providing full ventilatory support. It is intended to be used during 
activity, and there is inadequate evidence that it is beneficial in the treatment of any chronic lung disease. 
 
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 Life2000 System noninvasive ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued coverage for home ventilator, any type, used with 
non-invasive interface (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 23430 and 20680 billed for date of service 
August 22, 2022. 
 You asked the Plan to pay for procedure codes 23430 and 20680. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says the payment for these 
services is included in the payment for code 23472. 
 
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 23430 is a column II code to column I code 23472; however, 23430 
was billed with a modifier.  
 
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 procedure codes 23430 and 20680. Our reviewer says that 
these services are not supported for reporting in this case. Our reviewer found that although the medical records 
include documentation of a tinodesis of long tendon of biceps, there is also documentation that procedure 
23472, a total shoulder (glenoid and proximal humeral replacement (total shoulder)) arthroplasty of the 
glenohumeral joint was performed, therefore procedure 23430 is considered inclusive to procedure 23472. Per 
NCCI rules, a modifier is allowed to unbundle the relationship of the two codes, providing the documentation 
in the patient's medical record for the encounter supports the use of an appropriate modifier. In this case, the 
medical records do not include sufficient documentation to support the use of Modifier 59. In addition, the 
records do include documentation of a deep removal of an implant (20680) being performed, this service would 
also be considered an integral part of procedure code 23472. Per the National Correct Coding Initiative Policy 
Manual, "If a superficial or deep implant (e.g., buried wire, pin, rod) requires surgical removal (CPT codes 
20670 and 20680), it is not separately reportable if it is performed as an integral part of another procedure." 
Therefore, we find that these services were not reported appropriately in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 23430 and 20680 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 23430 and 20680 billed for date of service August 22, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on February 15, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that you have provided medical records to support 
the medical necessity of these items. The Plan denied your request. The Plan says you billed an incorrect pair 
of diagnoses on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. 
 
In this case, you billed this claim with diagnoses of E11.65 and E13.40. Code E13.40 is an Excludes1 code 
under code E11.65, so these two diagnoses cannot be billed together. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the diabetic supplies have not been met. Therefore, we decided that the Plan does not have to pay 
for diabetic supplies provided on February 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) billed with code 
E0675 for dates of service March 22, 2022, to April 11, 2022. 
 
You asked the Plan to pay for E0675. You say that this item was medically necessary for the patient's post-
operative treatment. The Plan denied your request. The Plan says PCDs coded as E0675 are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that PCDs coded as E0675 are not covered as they 
are considered not reasonable and necessary.  The PCD in dispute in this case was coded as E0675, so this item 
is not a covered benefit. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of E0675 have not been met. Therefore, we decided that the Plan does not have to pay for the 
pneumatic compression device (PCD) billed with code E0675 for dates of service March 22, 2022, to April 11, 
2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Syfovre. 
 
You asked the Plan to pre-approve Syfovre. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says that the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 Syfovre. Our reviewer says that the 
documentation supports that the requested drug is medically reasonable and necessary. Our physician reviewer 
found the enrollee has a diagnosis of geographic atrophy secondary to Nonexudative age-related macular 
degeneration. The Food and Drug Administration has stated that the requested drug is indicated for the 
enrollee's condition. The elements of the coverage criteria are satisfied. Therefore, the enrollee meets criteria 
for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Syfovre have been met. Therefore, we decided that the Plan has to pre-approve 
Syfovre.  
 
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.