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

 
We decided that the Plan does not have to pay for the pneumatic compression devices (E0675, E0673) 
provided on March 9, 2023. 
 
You asked the Plan to pay for the pneumatic compression devices. 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 items at issue in this appeal were for use outside of the home. Although these items 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 devices (E0675, E0673) provided on March 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 96365, 96366, and 96521 for date of service April 26, 
2023. 
 
You asked the Plan to pay for codes 96365, 96366, and 96521. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed 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. 
 
We find that codes 96365, 96366, and 96521 are not supported in the medical record. Specifically, the 
documentation shows that Outpatient Intravenous Insulin Treatment (OIVIT) either pulsatile or continuous, by any means, guided by the results of measurements for: respiratory quotient; and/or, urine urea nitrogen (UUN); 
and/or, arterial, venous or capillary glucose; and/or potassium concentration was performed. This means codes 
96365 and 96366 are not supported. There is a more appropriate code to be billed for the services rendered. The 
medical records submitted include an order to perform refilling and maintenance of portable pump. However, 
the records indicate that Outpatient Intravenous Insulin Treatment (OIVIT) was performed and does not 
include a procedure report for pump maintenance refill. Therefore, code 96521 cannot be verified. Based on 
this information, we decided that Medicare rules for coverage of codes 96365, 96366, and 96521 have not been 
met. Therefore, we decided that the Plan does not have to pay for codes 96365, 96366, and 96521 for date of 
service April 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on October 28, 2022. 
 
You asked the Plan to pay for the office visit. You say that you were told no authorizations were required 
through the end of 2022. The Plan denied your request. The Plan says an office visit is not a covered 
chiropractic service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on October 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says the 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 that the complexity of the enrollees nursing, medical, and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee can receive further services at a lower 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as the enrollee 
is not yet stable and as it would not be clinically advantageous.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J1817 billed for date of service March 1, 
2023. 
 
You asked the Plan to pay for procedure code J1817. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the service billed. 
 
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 J1817 is: Insulin for administration through durable 
medical equipment (DME) (i.e., insulin pump) per 50 units. 
 
 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 code J1817. Our reviewer says that procedure 
code J1817 does not meet criteria for payment. Our reviewer found that the procedure report describes 
intravenous insulin treatment provided for an outpatient. In this case, procedure code J1817 is the incorrect 
procedure to report for the service documented. 
 
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 code J1817 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code J1817 billed for date of service March 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facial feminization surgery (14041, 67900, 21137, 
21209). 
 
You asked the Plan to pre-approve facial feminization surgery. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 facial feminization surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record provided is insufficient to support the medical necessity of the 
requested service. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The 
requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facial feminization surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve facial feminization surgery (14041, 67900, 21137, 21209).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93970 billed for date of service March 24, 
2023.   
You asked the Plan to pay for procedure code 93970. You say that the records show that this 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 93970 is 1 unit. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide the required evidence showing that the excess units were 
actually provided. Only one report was submitted for review. Based on this information, we decided that 
Medicare rules for coverage of procedure code 93970 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 93970 billed for date of service March 24, 2023.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from November 8, 2022, to 
December 7, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered as billed. 
 
The Plan follows Medicare rules. The rules state that home health services under a plan of care are paid based 
on a 30-day period of care. The rules say that when periods of care are created from a notice of admission, the 
common working file (CWF) calculates a period end date that does not exceed the start date plus 29 days. 
 
The file shows that the start of care date is November 8, 2022. The claim dates do not exceed the start date plus 
29 days. Therefore, we decided that the Plan has to pay for the home health services provided from November 
8, 2022, to December 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 codes 92546 and 92547 billed for date of service 
April 24, 2023.  
 
You asked the Plan to pay for procedure codes 92546 and 92547. You say that the claim is billed correctly and 
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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT codes 92546 and 92547 is 1. The MAI value for these codes is 3. You billed 2 
units of code 92546 and 5 units of code 92547, exceeding the MUE. You did not provide all the required 
evidence showing that the excess units were actually provided, were correctly coded, and were medically 
necessary. Based on this information, we decided that Medicare rules for coverage of procedure codes 92546 
and 92547 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
92546 and 92547 billed for date of service April 24, 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 the enrollee needs additional physical and 
occupational therapy that would put them at risk if they do not get the additional support that is needed. 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an advanced knee feature (L5814, L5845, L5848, L5850, L5925) 
for a prosthetic leg. 
 
You asked the Plan to pre-approve an advanced knee feature. You say that the requested items are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that the requested items exceed the 
enrollee's medical needs. 
 
The Plan follows Medicare rules. Medicare rules say that that a lower limb prosthesis is covered when the 
beneficiary: 
1. Will reach or maintain a defined functional state within a reasonable period of time; and 
2. Is motivated to ambulate. 
 
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 an advanced knee feature. Our reviewer 
says that an advanced knee feature is medically reasonable and necessary in this case. Our physician reviewer 
found that the medical record demonstrates that the enrollee has a K3 functional level. The Plans denial letter 
sets more stringent requirements than Medicare and seeks to create strict use-case criteria with a level of 
specificity that does not appear in the Medicare rules. The medical record in this case more than meets the 
standards for documentation. There is no doubt that original Medicare would cover the requested prosthesis for 
the K3-level enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an advanced knee feature have been met. Therefore, we decided that the Plan 
has to pre-approve an advanced knee feature (L5814, L5845, L5848, L5850, L5925) for a prosthetic leg.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. A home ventilator was prescribed because of carbon dioxide (CO2) retention, but there is no arterial 
blood gas analysis (ABG) done while stable to document chronic CO2 retention. If that is present, the enrollee 
may benefit from bilevel positive airway pressure (BiPAP) with average volume-assured pressure support 
(AVAPS) during sleep as an outpatient. Medicare does not cover a home ventilator when used at settings that 
can be provided with BiPAP.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cyclobenzaprine HCL (J8499). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cyclobenzaprine HCL 
(J8499).  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 84165 billed for date of service May 11, 
2023.  
 
You asked the Plan to pay for procedure code 84165. You say that these services 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 84165 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 84165 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 84165 billed for date of service May 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 96365, 96366, and 96521 for date of service April 5, 
2023. 
 
You asked the Plan to pay for codes 96365, 96366, and 96521. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed 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. 
 
We find that codes 96365, 96366, and 96521 are not payable as billed. Specifically, the documentation shows 
that Outpatient Intravenous Insulin Treatment (OIVIT) either pulsatile or continuous, by any means, guided by 
the results of measurements for: respiratory quotient; and/or, urine urea nitrogen (UUN); and/or, arterial, 
venous or capillary glucose; and/or potassium concentration was performed. This means codes 96365 and 
96366 are not supported. There is a more appropriate code to be billed for the services rendered. The medical records submitted include an order to perform refilling and maintenance of portable pump. However, the 
records indicate that Outpatient Intravenous Insulin Treatment (OIVIT) was performed and does not include a 
procedure report for pump maintenance refill. Therefore, code 96521 cannot be verified. Based on this 
information, we decided that Medicare rules for coverage of codes 96365, 96366, and 96521 have not been 
met. Therefore, we decided that the Plan does not have to pay for codes 96365, 96366, and 96521 for date of 
service April 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve elective bilateral tubal ligation (58671). 
 
You asked the Plan to pre-approve elective bilateral tubal ligation. You say that the service is necessary. The 
Plan denied your request. The Plan says the requested service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that sterilization is covered under specific 
circumstances. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of elective bilateral tubal ligation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve elective bilateral tubal ligation (58671).