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

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 3 sensor. 
 
You asked the Plan to pre-approve the continuous glucose monitor (CGM). You say that the CGM is medically 
necessary. The Plan denied your request. The Plan says the CGM is not covered by Medicare or the enrollee's 
Health Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.   
We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device had not been reviewed by the PDAC prior to June 15, 2023. As such, this non-adjunctive 
CGM device is not eligible for coverage. Therefore, we decided that the Plan does not have to pre-approve the 
Freestyle Libre 3 sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman GS MIS Fusion Plate. 
 
You asked the Plan to pre-approve the Minuteman device. You say that this procedure is medically necessary 
for the enrollee. The Plan denied your request. The Plan says this device has not been found to be better or 
safer than standard devices. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Minuteman device. Our reviewer 
says that the requested Minuteman device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found current evidence-based medical guidelines and peer-reviewed literature do not 
fully support the interspinous fusion device procedure over the gold standard of lumbar fusion. There is a lack 
of large-volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical condition as discussed above. The reviewer found that the HA Minuteman G3-R MIS Fusion Plate is 
intended for use with bone graft material and is not intended for stand-alone use. The reviewer also found that 
there was no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the requested Minuteman GS MIS fusion plate 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 Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman GS MIS Fusion Plate.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methylprednisone. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the denial. 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 Methylprednisone.   
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor, segmental home model with 
calibrated gradient pressure (E0652) and segmental pneumatic appliance for use with pneumatic compressor, 
chest (E0657). 
 
You asked the Plan to pre-approve a pneumatic compressor and a chest segmental pneumatic appliance. 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 follows Medicare rules. Medicare rules say that a segmented, calibrated gradient pneumatic 
compression device (HCPCS code E0652) is only covered when the individual has unique characteristics 
which prevent them from receiving adequate satisfactory pneumatic compression treatment using a 
nonsegmented device along with a segmented appliance or compression device without manual control of the 
pressure in each chamber. 
 
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 pneumatic compressor and a chest 
segmental pneumatic appliance. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found the lymphedema does not extend into the chest, trunk or abdomen. 
 
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 pneumatic compressor and a chest segmental pneumatic appliance have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor, segmental 
home model with calibrated gradient pressure (E0652) and segmental pneumatic appliance for use with 
pneumatic compressor, chest (E0657).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth simulator (E0747).  
 
You asked the Plan to pre-approve a bone growth simulator (E0747) . You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 
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 bone growth simulator (E0747) . Our 
reviewer says that the item is not medically necessary. Our physician reviewer found there is no clinical 
rationale for the requested bone growth stimulator. 
 
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 bone growth simulator (E0747)  have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a bone growth simulator (E0747).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from November 
26, 2022, to December 25, 2022. 
 You asked the Plan to pay for SNF care. You say that the services were medically necessary. The Plan denied 
your request. The Plan says there was no daily skilled nursing or therapy services needed. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from November 26, 2022, to December 25, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for nerve conduction studies (95910 and 95886) provided on February 14, 
2023. 
 
You asked the Plan to pay for nerve conduction studies. You say that these services were necessary and were 
reported appropriately. The Plan denied your request. The Plan says that this claim was submitted with 
diagnosis codes G56.01 and M54.12, which cannot be reported together. 
 
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. Specifically, we were unable to verify the existence of an Excludes1 note 
between codes G56.01 and M54.12. There is no specific rule which excludes the use of these two codes 
together, and they are reporting different conditions for different body parts (the upper right limb and the 
cervical region). The Plan has not substantiated their denial in this case. Therefore, we decided that the Plan has 
to pay for nerve conduction studies (95910 and 95886) provided on February 14, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 29, 2022 
to October 28, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this service was medically 
necessary. 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 September 29, 2022 to 
October 28, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 88321 and 88377 billed for date of service February 9, 
2023. 
 
You asked the Plan to pay for procedure codes 88321 and 88377. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says that this claim is denied. 
 
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. Specifically, the Plan has not provided a clear reason for denial in this case, and 
this reason has not been supported with evidence and a relevant citation. The Plan has not substantiated their 
denial in this case. Therefore, we decided that the Plan has to pay for procedure codes 88321 and 88377 billed 
for date of service February 9, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alginate or other fiber gelling dressing (A6196) provided 
on December 30, 2022. 
 
You asked the Plan to pay for procedure code A6196. You say that the claim should be paid. The Plan denied 
your request. The Plan says procedure code A6196 has a status code of P. 
 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 A6196, which has a status indicator of 'P' on the CMS Physician Relative Value 
File, is always bundled into payment for other services not specified and no separate payment is made per 
Medicare. Based on this information, we decided that Medicare rules for coverage of procedure code A6196 
have not been met. Therefore, we decided that the Plan does not have to pay for the alginate or other fiber 
gelling dressing (A6196) provided on December 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 1, 2022, 
to September 30, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have submitted the required 
NOA. 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 September 1, 2022, to 
September 30, 2022.  
 
Please note that this decision is limited to the Plans original claim denial.  If you have questions regarding any 
corrected claim you may have submitted, you must send those to the Plan directly.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 10140, 93280, and 99215 rendered on 
January 24, 2023.  
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 10140, the 
procedure report describes relocation of pacemaker pocket, with irrigation performed.  In this case, incision and 
drainage of hematoma, seroma or fluid collection cannot be verified, as this procedure is not documented. In 
terms of CPT 93280, the procedure report describes pacemaker relocation and programming during same 
session.  In this case, modifier 59 distinct procedural service cannot be verified, as the programing would be 
included in the primary procedure which in this case would be relocation of pacemaker. Finally, in terms of 
CPT 99215, the evaluation and management service provided does not include documentation to support a 
separate procedure, as this procedure describes evaluation and management of the pacemaker. Therefore, CPT 
99215 separately cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. 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 procedure codes 10140, 93280, and 99215 rendered on January 24, 2023.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from March 28, 2022, to April 1, 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 that the NOA was not submitted timely. 
 
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. Specifically, the Plan's denial indicates that the NOA pertaining to this claim 
was received more than 30 days from the timely filing date. However, the Plan has not provided a copy of the 
untimely NOA nor a reliable date of untimely submission. It is the Plan's responsibility to support its denial 
with evidence. In this case, the Plan's denial has not been supported, so we must find in your favor. Therefore, 
we decided that the Plan has to pay for home health services provided from March 28, 2022, to April 1, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, and 87798, 
billed for date of service February 15, 2023. 
 You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653, and 87798. The Plan denied your 
request. The Plan says payment for codes 87150, 87481, 87641, 87653, and 87798, is bundled. 
 
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 87150 
is a column II code to column I code 87500. We have also confirmed that codes 87481, 87641, 87653, and 
87798, are column II codes to column I code 87150. This claim has not been billed with an appropriate 
modifier to bypass the edit. 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 codes 87150, 87481, 87641, 87653, and 
87798, billed for date of service February 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex device insertion. 
 
You asked the Plan to pre-approve the Coflex device insertion. You say that you have tried medication, 
physical therapy, and acupuncture without relief. You say that you have no quality of life, and the surgery 
should be approved. The Plan denied your request. The Plan says there are not enough studies to show that the 
Coflex device is safe and effective to treat back pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Coflex device insertion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the Coflex device is experimental. 
  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 Coflex device insertion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Coflex device insertion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit billed with code 99213 for February 3, 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 the claim has not been processed by the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has the Plan has 
not received an explanation of benefits (EOB) from the primary insurer. As the secondary insurer, the Plan 
cannot be held responsible for these services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for the office visit billed with code 99213 for 
February 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 19, 2022, to June 
17, 2022. 
 You asked the Plan to pay for the home health services. You say that you believe the claim was submitted 
timely. 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 May 19, 2022. The NOA was not received by the Plan until August 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 home health services provided 
from May 19, 2022, to June 17, 2022.