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

 
We decided that the Plan does not have to pre-approve a standard wheelchair. 
 
You asked the Plan to pre-approve a standard wheelchair. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested item is not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a wheelchair. The enrollees current wheelchair serves the same purpose as 
a standard wheelchair. The documentation does not support that the replacement is being requested due to loss 
or irreparable damage. Therefore, we decided that the Plan does not have to pre-approve a standard wheelchair.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 2, 2023, to 
January 3, 2023. 
 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 the services are not covered as 
billed. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and the rules. The claim was billed with a type of bill 323. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from January 2, 2023, to January 3, 
2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug services billed with code J3490 for March 29, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that intraoperative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. Procedure code J3490 was related to and billed on the same date of 
service as minor surgical procedure 27096. Payment for code J3490 is included in the global surgical payment 
for code 27096. Therefore, we decided that the Plan does not have to pay for the drug services billed with code 
J3490 for March 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 20, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A6209 billed for date of service January 14, 
2023. 
 
You asked the Plan to pay for procedure code A6209. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code A6209 is considered bundled and not separately payable.  
 
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 A6209 has a status indicator of P on the Physician Fee Schedule. This means that procedure code A6209 is bundled/excluded from payment. Based on this information, we decided that 
Medicare rules for coverage of procedure code A6209 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code A6209 billed for date of service January 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) and routine blood draw (36415) 
provided on February 12, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that a billing history report shows this claim was 
transmitted to the enrollee's Plan on February 18, 2021. You also say that the audit trail shows the claim was 
accepted when it was transmitted on the same day. The Plan denied your request. The Plan says the claim was 
not filed within one calendar year of the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the outpatient services was not filed until December 6, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the office visit (99214) and routine blood draw (36415) provided 
on February 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the replacement oxygen concentrator (E1390) and portable 
gaseous oxygen system, rental (E0431) provided February 1, 2023. 
 You asked the Plan to pay for the oxygen equipment replacement. You say that the medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says the rental or 
purchase guidelines were not met. 
 
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. The records indicate that the DME has been recently rented within a 
period of 30 days and therefore may still be under a rental agreement. Based on this information, we decided 
that Medicare rules for coverage of the oxygen equipment replacement have not been met. Therefore, we 
decided that the Plan does not have to pay for the replacement oxygen concentrator (E1390) and portable 
gaseous oxygen system, rental (E0431) provided February 1, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CardioMEMs device (93264) provided on February 1, 
2023. 
 
You asked the Plan to pay for the CardioMEMs device. You say that the device implantation (33289) was 
proven effective and has been paid, the monitoring of the device (93264) should also be paid. The Plan denied 
your request. The Plan says the clinical value and effectiveness of the CardioMEMs device 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 CardioMEMs device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the CardioMEMs System is considered to be medically necessary in enrollees 
diagnosed with New York Heart Association (NYHA) Class III heart failure with systolic or preserved ejection 
fraction who have been hospitalized for heart failure in the previous year. Our reviewer also found that the 
clinical value and effectiveness of the CardioMEMs device has not been demonstrated in the peer-reviewed 
literature. 
 
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 CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pay for the CardioMEMs device (93264) provided on February 1, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services billed with code 99285 
for January 1, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 4, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services billed with code 99285 for 
January 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed, heavy duty, extra wide, with weight 
capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress 
(E0303). 
 
You asked the Plan to pre-approve the hospital bed. You say that the provided records support the necessity of 
the item in dispute. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria. The Plan must follow Medicare rules. The rules say that a heavy duty extra wide hospital bed may be 
considered medically necessary if the beneficiary meets one of the criteria for a fixed height hospital bed and 
the beneficiary's weight is more than 350 pounds but does not exceed 600 pounds. 
 
We looked at the file and Medicare rules. The records show that the enrollee weighs 203 pounds. Based on this 
information, we decided that Medicare rules for coverage of the hospital bed have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a hospital bed, heavy duty, extra wide, with weight capacity 
greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress (E0303).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hereditary cancer panel testing. 
 
You asked the Plan to pre-approve hereditary cancer testing. You say that you have extensive family history of 
cancer, so this testing is necessary and will help you be proactive in any future treatment you may need. The 
Plan denied your request. The Plan says the requested test is considered a screening as you have no personal 
history of cancer and therefore is not covered by Medicare. The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, hereditary cancer testing, is being requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pre-approve hereditary cancer panel testing.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 for date of service November 23, 
2022. 
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 11, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for procedure code 99285 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99285 for date of service 
November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93288 billed for date of service February 27, 
2023.  
 
You asked the Plan to pay for procedure code 93288. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 93288 is bundled into payment for code 93294. 
 
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 93288 
is a column II code to column I code 93294 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 93288 billed for date of service February 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing, and the mass spectrometry and tandem mass 
spectrometry provided on January 24, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the drug testing, and the mass spectrometry and tandem mass spectrometry. You 
say that these services were medically necessary. The Plan denied your request. The Plan says enrollees must 
receive their care from a network provider. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
items/services at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the drug testing, and the mass spectrometry and 
tandem mass spectrometry provided on January 24, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an office visit (92928, 99215, 0715T) provided on December 6, 2022. 
 
You asked the Plan to pay for the office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that they were unable to review the appeal in the allowed timeframe. 
 
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 did not fully articulate their reason for the denial, or cite the Medicare 
rules used to make the determination. No records were provided to show if this service was included in another 
service. Therefore, we decided that the Plan has to pay for an office visit (92928, 99215, 0715T) provided on 
December 6, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for dates of service November 
22, 2022, to November 29, 2022. 
 You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
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.  
 
In this case, the NOA was not received by the Plan. No payment can be made on this claim. Therefore, we 
decided that the Plan does not have to pay for home health services billed for dates of service November 22, 
2022, to November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 billed for date of service December 9, 
2022. 
 You asked the Plan to pay for procedure code 99152. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says payment for code 99152 is included in the payment for 
code 45385. 
 
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 99152 is a column II code to column I code 45385; however, 99152 
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 code 99152. Our reviewer says that procedure 
code 99152 does not meet criteria for payment. Our reviewer found that the provider performed a colonoscopy 
with sedation services. In this case, procedure code 99152 is an inappropriate code to report for colonoscopy 
service. There is a more appropriate code to report for the anesthesia service provided. 
 
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 99152 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99152 billed for date of service December 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye examination received March 23, 2023, from an out-
of-network provider.  
You asked the Plan to pay for an eye examination with an out-of-network provider. You say that you went to 
this provider because you do not like the contracted provider. The Plan denied your request. The Plan says 
vision services are only covered when you use an in-network provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you utilize an in-network provider. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of an eye examination with an out-of-network provider have not been met. Therefore, we decided that 
the Plan does not have to pay for an eye examination received March 23, 2023, from an out-of-network 
provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 3, 2022, to 
November 1, 2022. 
 You asked the Plan to pay for the home health services. You say that your software couldn't bill NOAs at the 
time of admission. 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 October 3, 2022. The NOA was not received by the Plan until December 
23, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from October 3, 2022, to November 1, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service November 8, 
2022.  
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. 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 99285 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, 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 code 99285 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99285 billed for date of service November 8, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 for date of service January 20, 2023. 
 
You asked the Plan to pay for procedure code 99284. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 10, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for procedure code 99284 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99284 for date of service January 
20, 2023.