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

 
We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277). 
 
You asked the Plan to pre-approve a powered pressure-reducing air mattress. 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 
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 a powered pressure-reducing air 
mattress. Our reviewer says that the requested item is not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee has limited mobility due to a medical condition. The 
documentation doesnt support that the enrollee has multiple stage 2 pressure ulcers located on the trunk or 
pelvis and has failed to improve in the previous month with conservative treatment with a comprehensive ulcer 
treatment program or a myocutaneous flap or skin graft. 
 
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 powered pressure-reducing air mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277).
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 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 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. 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 this enrollee 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation code A0425 billed for date of 
service November 7, 2022. 
 You asked the Plan to pay for the billed services. You say that the enrollee was transported to the closest 
accepting facility. The Plan denied your request. The Plan says the billed units exceed the maximum allowed. 
 
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 MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 321 units of 
this code on one line, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
the ambulance transportation code A0425 billed for date of service November 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on January 16, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 
 
 The claim shows the services were provided in an ambulatory surgical center. Although this item may be 
helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that 
the Plan does not have to pay for the pneumatic compression device provided on January 16, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on December 8, 2022. 
 
You asked the Plan to pay for the home health services . You say that the submitted records should be 
reviewed, and the 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 November 8, 2022. The NOA was not received by the Plan until January 
23, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided on December 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services billed with Patient-Driven 
Grouping Model (PDGM) 2HB11 provided on April 19, 2022, to May 18, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the PDGM billed is not supported. 
 
The Plan follows Medicare rules. Medicare rules say that home health services must be billed with the correct 
PDGM. 
 
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 home health services as billed. Our 
reviewer says that the PDGM billed is not supported. Our physician reviewer found the enrollee received home 
health services. The record does include physical therapy visit notes although there is no evaluation. The record 
includes only 2 skilled nursing visits. Therefore, the billing of PDGM 2HB11 is not supported. 
 
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 home health services as billed have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health services billed with Patient-Driven Grouping Model 
(PDGM) 2HB11 provided on April 19, 2022, to May 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on February 4, 2023, billed with 
procedure code 73630-26-RT. 
 
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 the diagnosis is inconsistent with the procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes specific to the left side are not 
appropriate for lines with modifier RT (right) appended, diagnosis codes specific to the right side are not 
appropriate for lines with modifier LT (left) appended, and diagnosis codes for an unspecified side are not 
appropriate for lines with modifiers RT (right), LT (left) or 50 (bilateral) appended.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services provided have not been met. This claim was billed with diagnosis code 
M86.9, described as Osteomyelitis, unspecified, which is inappropriate for a line with an RT modifier 
appended. Therefore, we decided that the Plan does not have to pay for imaging services provided on February 
4, 2023, billed with procedure code 73630-26-RT.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0482 for date of service November 8, 2022. 
 
You asked the Plan to pay for code G0482. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be submitted with complete 
information. 
 
We looked at the file and Medicare rules. Review of the file shows that the location of where the service was 
rendered (item 32) was not filled out on the submitted claim. Based on this information, we decided that 
Medicare rules for coverage of code G0482 have not been met. Therefore, we decided that the Plan does not 
have to pay for code G0482 for date of service November 8, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for electromyography procedures (EMG) provided on March 7, 2022. 
 
You asked the Plan to pay for the electromyography procedures (EMG). You say that the requested 
electromyography procedures (EMG) was medically necessary. The Plan denied your request. The Plan says 
that the requested electromyography procedures (EMG) does not meet the Medicare LCD coverage criteria.  
 
The Plan follows Medicare rules. Medicare rules say that electromyography procedures (EMG) is covered 
when the criteria listed in the Medicare rules section of this decision are met.  
 
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 electromyography procedures (EMG). 
Our reviewer says that the requested electromyography procedures (EMG) is medically necessary. Our 
physician reviewer found review of the current peer-reviewed medical literature indicates that EMG, short-
latency somatosensory evoked potential study and motor evoked potential testing are standard of care for 
cervical spine surgery. As summarized in Up to Date: Neuromonitoring in surgery and anesthesia, 
"Electrophysiologic monitoring, or neuromonitoring, is used during surgery to assess the functional integrity of 
the brain, brainstem, spinal cord, or peripheral and cranial nerves. The goal of monitoring is to alert the surgeon and anesthesiologist to impending injury in order to allow modification of management in time to prevent 
permanent damage. In some cases, neuromonitoring is used to map areas of the nervous system in order to 
guide procedural management."  
 
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 electromyography procedures (EMG) have been met. Therefore, we decided 
that the Plan has to pay for electromyography procedures (EMG) provided on March 7, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service January 25, 
2023.  
  You asked the Plan to pay for procedure code 99233. You say that the enrollee was seen by another provider 
with a different specialty and the claim should be reprocessed for payment. The Plan denied your request. The 
Plan says payment for code 99233 is bundled into payment for code 90791. 
 
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 99233 
is a column II code to column I code 90791 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 99233 billed for date of service January 25, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 10, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 indicates 
that the two conditions cannot occur together.  
 
We looked at the file and Medicare rules. The claim in this case was billed with diagnosis codes I51.9 and 
I08.3. Diagnosis code I51.9 has an Excludes1 note and cannot be billed with diagnosis code I08.3. Based on 
this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the services provided on January 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bariatric surgery (43645, 43845). 
 
You asked the Plan to pre-approve bariatric surgery. You say that this procedure is medically necessary for the 
enrollee to lose weight. The Plan denied your request. The Plan says this procedure is not medically necessary 
as there is no documentation to support that the enrollee has actively participated in a weight-management 
program supervised by a health care professional for a minimum of four consecutive months out of the past 
year. 
 
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 bariatric surgery. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation indicates that the enrollee has been communicating with a 
nutritionist on a regular basis via telehealth visits. These encounters do not contain any current weight 
measurements (only weights for 2021). As the documented weight-management program does not include 
monthly documentation of enrollee's weight and BMI, Medicare criteria for coverage for the bariatric surgery 
are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bariatric surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve bariatric surgery (43645, 43845).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 6, 2022, to 
September 4, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the claim should be reprocessed 
because an NOA was sent and acknowledge by the Plan on May 25, 2022. The Plan denied your request. The 
Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 6, 2022, to 
September 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on February 3, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the 
ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, 
followed by the manifestation.  
 
We looked at the file and Medicare rules. Specifically, the record shows that the claim was billed with primary 
diagnosis code E08.21. This code has a code first note, which means it is a manifestation code and must be sequenced after an etiology code. Based on this information, we decided that Medicare rules for coverage of 
the billed services have not been met. Therefore, we decided that the Plan does not have to pay for the services 
provided on February 3, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, chest; 2 views, set-up portable x-ray 
equipment and transportation of portable x-ray equipment and personnel to home or nursing home on 
February 28, 2023. 
 
You asked the Plan to pay for radiologic examination, chest; 2 views, set-up portable x-ray equipment and 
transportation of portable x-ray equipment and personnel to home or nursing home. You say that the services 
were medically necessary. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 
approved in advance. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for radiologic examination, chest; 2 views, set-up portable x-ray 
equipment and transportation of portable x-ray equipment and personnel to home or nursing home on  
February 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on February 6, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 indicates 
that the two conditions cannot occur together.  
 
We looked at the file and Medicare rules. The claim in this case was billed with diagnosis codes D64.9 and 
D46.9. Diagnosis code D64.9 has an Excludes1 note and cannot be billed with diagnosis code D46.9. Based on 
this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the services provided on February 6, 2023.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided June 10, 2020, to June 22, 2020. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the physician certification was not received and documentation 
submitted does not support the services as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the Plan has denied this claim due to the physician 
certification was not received and documentation submitted does not support the services as billed. The 
documentation did not include Medicare rules that pertain to this denial. No explanation was provided to 
support why the documentation submitted did not support the services billed. No other denial rationale was 
provided. The Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the 
home health services provided June 10, 2020, to June 22, 2020.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty at T6 (22513). 
 
You asked the Plan to pre-approve a kyphoplasty. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says this procedure is not medically necessary. 
 
We reviewed the Local Coverage Determination cited by the Plan and found it was not applicable to the 
jurisdiction. 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 a kyphoplasty. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no documentation of bracing. More conservative measures are needed. 
 
 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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty at T6 (22513).