Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29881 billed for date of service January 20, 
2022. 
 You asked the Plan to pay for procedure code 29881. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says payment for code 29881 is bundled into payment for 
code 29876. 
 
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 procedure code 29881. Our reviewer says that the code at 
issue does not meet criteria for payment. Our reviewer found the procedure code at issue is not supported as a 
separately identifiable procedure. The record states that the synovectomy was performed in the same 
compartments as the meniscectomy and chondroplasty. These services are included in the main procedure and 
are not separately reportable. 
 
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 29881 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 29881 billed for date of service January 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve genetic testing. The Plan denied your request. The Plan says this is not 
covered for screening. 
 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 testing at issue in this appeal is being requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve genetic 
testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided August 24, 2022, 
to September 16, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you are providing clinical 
documentation so these medically necessary charges can be reviewed for approval and payment. The Plan 
denied your request. The Plan says the stay is denied. You may resubmit this claim under Part B. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee presented to the emergency department with low hemoglobin (6.7) sent 
from nursing home with recent episode of syncope at dialysis with hypotension. Troponin was normal, 
electrocardiogram (ECG) normal. The enrollee was treated with fluids. Hemoglobin was retested at 8. No 
transfusion was needed or given. Workup was otherwise negative without complexity at the time of admission, 
it was not expected that the enrollee would require hospital care that would likely cross 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided August 24, 2022, to September 16, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health aide hours. 
 
You asked the Plan to pre-approve the additional home health aide hours. You say that you need the additional 
32 hours a week as you need someone to stay with you at all times. The Plan denied your request. The Plan 
says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
 
 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 additional home health aide hours. 
Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found 
you are not homebound.  As such, the additional home health aide hours are not medically necessary, 
reasonable or coverable. 
 
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 additional home health aide hours have not been met. Therefore, we decided 
that the Plan does not have to pre-approve additional home health aide hours.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel provided on October 31, 
2022. 
 
You asked the Plan to pay for the respiratory pathogen panel. You say that this test was medically necessary 
and is supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the respiratory pathogen panel have not been met. Specifically, the service at issue is a test panel 
which was unbundled and billed as individual components. Therefore, we decided that the Plan does not have 
to pay for the respiratory pathogen panel provided on October 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan has to pay for prophylaxis - adult (D1110) provided on December 20, 2022. 
 
You asked the Plan to pay for dental services. You say that just because your cleanings were not exactly 6 
months apart, your insurance covers two cleanings so this service should be covered. The Plan denied your 
request. The Plan says that you received two cleanings, however they were not 6 months apart. Therefore, this 
service 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 did not send us the explanation of benefits (EOB) that we 
requested for date of service December 20, 2022. Without the EOB we cannot determine that you received this 
service, and the Plan did not make a payment. Therefore, we decided that the Plan has to pay for prophylaxis - 
adult (D1110) provided on December 20, 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 the laboratory test (0241U) provided on December 29, 2022. 
 
You asked the Plan to pay for the laboratory test. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory test 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test (0241U) 
provided on December 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport provided on November 23, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that the submitted medical records support the 
ambulance transport was medically necessary The Plan denied your request. The Plan says this claim does not 
meet the requirements for the ambulance transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service. Our reviewer says 
that the ambulance transport was not medically necessary.  Our physician reviewer found the transportation via ambulance from the hospital to the enrollee's residence 
upon discharge was not medically necessary. The enrollee did not require the expertise of trained personnel or 
the equipment available only on an ambulance in order to effectuate a safe transport. Transportation could have 
been provided by other means (stretcher van, wheelchair van, private car, taxi) without endangering the 
enrollee's condition. 
 
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 ambulance service have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance service, basic life support, non-emergency transport provided on 
November 23, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional skilled nursing and physical therapy home 
health care visits. 
 You asked the Plan to pre-approve the additional skilled nursing and physical therapy home health care visits. 
You say that the enrollee does remain homebound and ambulates with a walker within the home. You also say 
that her strength is improving but balance is poor especially if bending over. The Plan denied your request. The 
Plan says the additional services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional skilled nursing and 
physical therapy home health care visits. Our reviewer says that the services are not medically reasonable and 
necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. As 
such, the requested home health skilled nursing services are not medically necessary or reasonable. 
 
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 additional skilled nursing and physical therapy home health care visits. have 
not been met. Therefore, we decided that the Plan does not have to pre-approve additional skilled nursing and 
physical therapy home health care visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urgent care services provided on October 7, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the OON urgent care services. You say that the records provided support the 
need for the services in dispute. The Plan denied your request. The Plan says it was not medically necessary to 
receive care out-of-network. The Plan says that there was no network deficiency for these services and alternate 
in-network providers were found. 
 
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 
item/service 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 urgent care services provided on October 7, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item should be covered. The 
Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to 
prevent deep vein thrombosis. Claims for E0676 are statutorily denied as no Medicare benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subsequent nursing facility care visit (99308) provided on 
October 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a subsequent nursing facility care visit. You say that you disagree with the denial 
and request reprocessing of this claim. The Plan denied your request. The Plan says the enrollee must receive 
care from a network provider. The enrollee's primary care physician (PCP) or plan must give approval in 
advance before you can use providers not in the plans network. This is called 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. The records show that the requested visit was not an emergency visit. 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 a subsequent nursing facility care visit (99308) provided on October 28, 2022, by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-preferred diabetic testing supplies. 
 
You asked the Plan to pre-approve non-preferred supplies.. The Plan denied your request. The Plan says the 
enrollee does not meet the coverage criteria for a non-preferred item. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred or may limit the DME to only those preferred brands and manufacturers 
 
We looked at the file and Medicare rules. The records provided do not show that the enrollee is unable to use 
the Plans preferred products. Based on this information, we decided that Medicare rules for coverage of non-
preferred supplies. have not been met. Therefore, we decided that the Plan does not have to pre-approve non-
preferred diabetic testing supplies.
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 November 29, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services are separately 
payable. 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 
November 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an over-bed table. 
 
You asked the Plan to pre-approve an over-bed table. The Plan denied your request. The Plan says this item 
does not used for a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an over-bed table.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
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 services are not medically necessary. 
 
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. 
 
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 chronic respiratory failure consequent to chronic obstructive pulmonary disease (COPD). The records document that 
the ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with auto-
EPAP (AE), which could be provided by a BiPAP device with AVAPS and a back-up rate. The records do not 
document trial and failure of a BiPAP device with AVAPS and a back-up rate. A home ventilator is not 
covered for this use and is therefore not reasonable or medically necessary at this time. 
 
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 a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneDose Genetic Response Report (comprehensive 
hereditary pharmacogenomic testing) and the Hereditary Genetic Cardiac Test panel provided on November 3, 
2022.  
You asked the Plan to pay for GeneDose Genetic Response Report and the Hereditary Genetic Cardiac Test 
panel. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
services provided are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing is only covered for certain indications. 
 
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 GeneDose Genetic Response Report and the 
Hereditary Genetic Cardiac Test panel. Our reviewer says that the documentation does not support that the 
services rendered were medically reasonable or necessary. Our physician reviewer found there is no specific 
clinical rationale for the requested laboratory studies. The review has determined that the enrollee does not 
have a diagnosis/condition that met criteria for the services rendered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of GeneDose Genetic Response Report and the Hereditary Genetic Cardiac Test 
panel have not been met. Therefore, we decided that the Plan does not have to pay for GeneDose Genetic 
Response Report (comprehensive hereditary pharmacogenomic testing) and the Hereditary Genetic Cardiac 
Test panel provided on November 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you are in a wheelchair. You say that 
the left side of your body does not work. You say that you need this item. You also say that you do not want to 
end up in the hospital again with a bladder infection. The Plan denied your request. The Plan says the requested 
item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.