Persius/hicric huggingface dataset:
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 doctor feels you will greatly benefit from the 
therapy, and your back and legs need to be strengthened from the spine injury. The Plan denied your request. 
The Plan says that you do not meet the Medicare criteria for admission to an Inpatient Rehabilitation Facility. 
 
  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 your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S0630 billed for date of service November 
15, 2022. 
 
You asked the Plan to pay for procedure code S0630. You say that this should be paid for. 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 S0630 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S0630 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S0630 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S0630 billed for date of service November 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
Torticollis (cervical dystonia). He has not tried and failed one of the Plan's required drugs, Dysport or Xeomin. 
The records do not show that the required drugs would be contraindicated or less effective; therefore, Botox is 
not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Botox.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a water circulating heat pad with pump (E0217) provided on 
August 21, 2022, to September 9, 2022. 
 
You asked the Plan to pay for a water circulating heat pad with pump. You say that this item is medically 
necessary. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes E0215 or E0217 will be denied as not 
reasonable and necessary. 
 
We looked at the file and Medicare rules. The code at issue is not covered. Based on this information, we 
decided that Medicare rules for coverage of a water circulating heat pad with pump have not been met. 
Therefore, we decided that the Plan does not have to pay for a water circulating heat pad with pump (E0217) 
provided on August 21, 2022, to September 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 43239 billed for date of service July 19, 
2022. 
 You asked the Plan to pay for procedure code 43239. You say that this should be paid for. 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 43239 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 43239 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 43239 billed for date of service July 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a motorized scooter. 
 
You asked the Plan to pre-approve a motorized scooter. You say that you need a scooter for mobility outside 
the house. The Plan denied your request. The Plan says that the requested scooter is not covered for outside 
use. 
 
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 item at issue in this appeal is for use outside of the home. 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 pre-approve a motorized scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 5, 2023. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 
prior authorization. 
 
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 an office visit provided on January 5, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services billed for date of service August 8, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that this was an emergency transport, so it 
should be separately paid. The Plan denied your request. The Plan says the patient was an inpatient on August 
8, 2022, so the ambulance service is bundled into payment for the hospital facility. 
 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 ambulance services have been met. 
Specifically, the Plan has provided evidence that the patient was admitted to the hospital on August 7, 2022, 
and remained an inpatient until August 12, 2022. You billed for ambulance transport for date of service August 
8, 2022, which is in the middle of this inpatient stay.  However, a review of the transport records you provided 
indicates that the transport services actually occurred on August 7, 2022, NOT on August 8, 2022, as billed.  
You have provided no records or evidence that any transport occurred on August 8, 2022.  Without any such 
evidence, we cannot determine if ambulance services should be paid for date of service August 8, 2022. 
Therefore, we decided that the Plan does not have to pay for ambulance services billed for date of service 
August 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 24, 2022, to 
September 22, 2022. 
 You asked the Plan to pay for the home health services. You say that the NOA was sent on time. 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 25, 2022. The NOA was not received by the Plan until November 11, 
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 the home health services 
provided from August 24, 2022, to September 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 12, 2022, 
to March 13, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the claim was submitted 
correctly. 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 February 12, 2022, to 
March 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that you were advised at the facility that these would be 
fully covered by your insurance. You say that these were denied because you do not have diabetes. You say 
that since receiving this denial you have been diagnosed as pre-diabetic. You also say that you feel these should 
be covered. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment, methadone; weekly bundle including 
dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology 
testing provided on January 23, 2023. 
 
You asked the Plan to pay for medication assisted treatment, methadone; weekly bundle including dispensing 
and/or administration, substance use counseling, individual and group therapy, and toxicology testing. You say 
that you have been enrolled in the Medicare program to provide OTP services since January 1, 2020. The Plan 
denied your request. The Plan says that the claim for these drugs was billed by the physician, not the opioid 
treatment program (OTP) facility. 
 
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. The Plan rationale incorrectly states that this claim was submitted by a physician 
rather than the OTP facility. The claim shows that the billing provider is the OTP facility. This was submitted 
on a professional claim which is allowed according to the rules. As such, we find that the Plan has not 
substantiated this denial of payment. Therefore, we decided that the Plan has to pay for medication assisted 
treatment, methadone; weekly bundle including dispensing and/or administration, substance use counseling, 
individual and group therapy, and toxicology testing provided on January 23, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the removal of impacted cerumen requiring 
instrumentation (69210) provided on December 27, 2022. 
 
You asked the Plan to waive the copayment for the removal of impacted cerumen requiring instrumentation 
(69210). You say that the service should be covered. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $20 copayment for the removal of impacted cerumen requiring instrumentation 
(69210). This item/service falls within the physician/Practitioner services, including doctors office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the removal of impacted 
cerumen requiring instrumentation (69210) provided on December 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided July 11, 2022, to August 
9, 2022. 
 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 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 April 12, 2022. The NOA was not received by the Plan until September 2, 
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 the home health services 
provided July 11, 2022, to August 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS Oral Brush CDx biopsy test (88104, 88305, 
88312 and 88361) provided October 3, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that WATS3D cannot be considered 
experimental or investigational because it is recommended in the standard of practice guidelines of major 
medical societies. The Plan denied your request. The Plan says the clinical value and effectiveness of the 
WATS Oral Brush CDx biopsy test in the setting of a soft palate lesion has not been demonstrated in the peer 
reviewed literature. 
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of gastroesophageal reflux disease (GERD) who underwent 
WATS Oral Brush CDx biopsy test during Endoscopy. The literature states that the oral brush biopsy 
(OralCDx Brush Test), with or without melanoma-associated antigens A (MAGE-A) staining or glucose 
transporter (GLUT)-1 staining experimental and investigational for screening, diagnosis or surveillance of 
cancerous or pre-cancerous oral lesions because of insufficient evidence. As well, the esophageal brush biopsy 
(WATS3D, formerly known as EndoCDx) is considered experimental and investigational for screening, 
diagnosis or surveillance of cancerous or pre-cancerous esophageal lesions because of insufficient evidence. 
The review has determined that the requested item 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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the WATS Oral Brush CDx biopsy test (88104, 88305, 88312 and 88361) provided 
October 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliances (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you request 
the approval of the entire Flexitouch system and its components as medically necessary The Plan denied your 
request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there 
is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliances (E0667).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 26, 2023, to 
January 30, 2023. 
 
You asked the Plan to pay for the home health services. You say that this claim is a monthly bill and a Notice 
of Admission is not required. The Plan denied your request. The Plan says you did not bill with the correct 
Type of Bill (TOB) 
 
The Plan must follow Medicare rules. Medicare rules say that all home health prospective payment system (HH 
PPS) claims must be submitted with Type of Bill (TOB) 0329. 
 
Records show that you billed the HH PPS claim in dispute with TOB 322, not 329 as is required. Based on this 
information, we decided that Medicare rules for coverage of the home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services provided from January 26, 
2023, to January 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 73030, 23550, A4565, J0690, J1100, J2001, J2250, 
J2370, J2405, J2704, J2795, J3010, J7050, and J7120 for date of service February 16, 2022. 
 
You asked the Plan to pay for codes 73030, 23550, A4565, J0690, J1100, J2001, J2250, J2370, J2405, J2704, 
J2795, J3010, J7050, and J7120. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 73030, 23550, A4565, J0690, J1100, J2001, J2250, J2370, J2405, J2704, J2795, 
J3010, J7050, and J7120 are not supported in the medical record. Specifically, code 23550 is a device-
dependent procedure and was billed without a dependent device code. The added device code A4565 is not 
listed as a valid device code for device-dependent procedure 23550. Per the Data HCPCS table all billed 
procedure codes are listed as not applicable as a device to device dependent procedure 23550. Therefore, as a 
device code was not reported for device-dependent procedure 23550 and modifier CG, 52, 73 and 74 was not 
billed, and as the disposition of OCE 92 Edit is Claim Return to Provider (RTP). 
 
Based on this information, we decided that Medicare rules for coverage of codes 73030, 23550, A4565, J0690, 
J1100, J2001, J2250, J2370, J2405, J2704, J2795, J3010, J7050, and J7120 have not been met. Therefore, we 
decided that the Plan does not have to pay for codes 73030, 23550, A4565, J0690, J1100, J2001, J2250, J2370, 
J2405, J2704, J2795, J3010, J7050, and J7120 for date of service February 16, 2022.