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

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (PWC) with 
multiple power options (K0842) and additional accessories (codes E2361, E2311, E2377, E2313, E1012, 
E0955, E1028, and E1007).  
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that you are non-mobile 
and bed ridden 24 hours without this. The Plan denied your request. The Plan says your request is not 
medically necessary because the records indicate you were approved for a K0010 standard weight frame 
motorized/power wheelchair (K0010) under authorization # ending in 1556, and to be delivered to you on 
August 4, 2023.  
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 durable medical equipment (DME). 
Our physician reviewer found although your condition may meet criteria for a PWC, the criteria for this 
specifically requested PWC with multiple power options including upgraded electronics are not met. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (PWC) with multiple 
power options (K0842) and additional accessories (codes E2361, E2311, E2377, E2313, E1012, E0955, E1028, 
and E1007).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the enrollee is at high risk for hospital 
readmission and potentially life-threatening exacerbations. The Plan denied your request. The Plan says the 
enrollee's needs could be met by a bilevel positive airway pressure (BiPAP). 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home ventilator. Our physician 
reviewer found there is no diagnosis of COPD, thoracic restrictive disease, or neuromuscular disease. Medicare 
does not cover a home ventilator for diagnoses of restrictive lung disease or obesity hypoventilation syndrome. 
There is no documentation that BiPAP has been tried and failed as an outpatient. The denial was upheld. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS HF device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no indication that the enrollee is in a clinical trial of the device. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical 
management.  
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS HF device.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on November 30, 2022, billed with 
procedure code 76882-26-LT. 
 
You asked the Plan to pay for the testing services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that the diagnosis is not consistent with the 
procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that Providers or suppliers shall use anatomic 
modifiers and report procedures with differing modifiers on individual claim lines when appropriate.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing services provided have not been met. Diagnosis code R22.30 is not appropriate for lines 
with modifier LT (left) appended when a more appropriate diagnosis is available. Therefore, we decided that 
the Plan does not have to pay for testing services provided on November 30, 2022, billed with procedure code 
76882-26-LT.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 3, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reconsidered. The Plan 
denied your request. The Plan says you did not timely file your claim. 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 lab services was not filed until April 6, 
2023. 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 lab services provided on February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the emergency medical evaluation 
provided on February 1, 2023.  
 
You asked the Plan to provide reimbursement for the evaluation. You say that you paid a lot of money to this 
provider for emergency care and feel you should be reimbursed.  The Plan denied your request. The Plan says 
while the medical records were received, there is no proof of payment for this date of service. 
 
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 evaluation have been met. While there are receipts for several drugs included, the file did not include a receipt or bank document showing that 
payment was made for the services at issue. Without proof of payment, reimbursement cannot be approved. 
Therefore, we decided that the Plan does not have to provide reimbursement for the emergency medical 
evaluation provided on February 1, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for imaging services coded as 93306 performed on March 11, 2023. 
 
You asked the Plan to pay for 93306. You say that 93306 should be paid as billed because the diagnosis codes 
are accurate. The Plan denied your request. The Plan says that payment is not allowed for 93306 because the 
diagnosis codes are inappropriately reported.  
 
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 (Independent Review Entity) 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. It is not clear from the Excludes1 note found under diagnosis code I51.7, defined 
as cardiomegaly, that this code cannot be reported with diagnosis code I11.0, defined as hypertensive heart 
disease with heart failure. While the Excludes1 note states I51.7 cannot be billed with any condition in I51.4-
I51.9 due to hypertension (I11.-, it does not specifically state that I51.7 cannot be billed with I11.0. Therefore, 
we decided that the Plan has to pay for imaging services coded as 93306 performed on March 11, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reconsidered. The Plan 
denied your request. The Plan says you did not timely file your claim. 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 lab services was not filed until April 3, 
2023. 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 lab services provided on October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 9, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reconsidered. The Plan 
denied your request. The Plan says you did not timely file the claim for these services. 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 lab services was not 
filed until April 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 lab services provided on 
February 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99349 billed for date of service March 29, 2023. 
 
You asked the Plan to pay for code 99349. You say that other claims for this member were processed with the 
same diagnosis codes. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be 
reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that F03.93 has an Excludes1 note in relation to F06.70. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for code 99349 have not been met. Therefore, we decided that the Plan does not have to pay for 
code 99349 billed for date of service March 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 22, 2021. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you did not timely file this claim. 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 lab services was not 
filed until March 6, 2023. 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 lab services provided on 
March 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87801, 87481, 87653 and 87798 billed for 
date of service February 24, 2023. 
 You asked the Plan to pay for procedure codes 87801, 87481, 87653 and 87798. You say that these services 
were necessary and are supported in the medical record. The Plan denied your request. The Plan says these 
codes are not supported 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. 
 
In this case, we have confirmed that codes 87481, 87653 and 87798 are column II codes to column I code 
87801; however, codes 87481, 87653 and 87798 were each 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 codes 87801, 87481, 87653 and 87798. Our 
reviewer says that these codes are not supported in the medical record. Our reviewer found that the provider 
reported 3 units of service for code 87801; however, CPT codes that test for multiple infectious agents are 
reported with one unit of service if one procedure, one methodology, or one test kit is used to perform the test. 
Therefore, this procedure denied appropriately, as this service was billed incorrectly. In addition, the provider 
reported procedure codes 87481, 87653 and 87798 with modifier XU (unusual non-overlapping service) to 
bypass the NCCI edit; however, the documentation does not support that these services were unusual non-
overlapping services to code 87801. It is not appropriate to report these codes separately in this case. 
 
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 codes 87801, 87481, 87653 and 87798 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 87801, 87481, 87653 and 87798 billed for 
date of service February 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive carrier genetic testing panel (81243, 81329, 
81161, 81443) provided on September 26, 2022. 
 
You asked the Plan to pay for a comprehensive carrier genetic testing panel. You say that this is supported in 
the records. The Plan denied your request. The Plan says this is not a covered service. 
 
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 rules also say that Genetic Testing and Genetic 
Counseling (when applicable) for carrier screening may not be relevant to a Medicare beneficiary or may not 
meet a Medicare benefit category and/or reasonable and necessary threshold for coverage. 
 
The test at issue in this appeal, a comprehensive carrier genetic testing panel, was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Medicare also does not 
cover carrier screening. Therefore, we decided that the Plan does not have to pay for a comprehensive carrier 
genetic testing panel (81243, 81329, 81161, 81443) provided on September 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 9, 2023, to 
March 10, 2023.  
 You asked the Plan to pay for the home health services. You say that you timely filed the NOA. The Plan 
denied your request. The Plan says the required NOA has not been received. 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 Plan has confirmed that no valid NOA has been received. As a result, no payment can be made 
on this claim. Please note that although you claim a NOA was submitted, the document you provided as proof 
of submission does not show that you submitted the NOA to the Plan, but rather you submitted it to the 
Original Medicare intermediary. Therefore, we decided that the Plan does not have to pay for home health 
services provided from February 9, 2023, to March 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Big Bounder 600 power wheelchair (K0899), increase 
maximum user weight to 700 pounds (K0108), power seating system, tilt only (E1002), extra heavy duty power 
seating upgrade (K0108), power seating system booster (K0108), custom rear wheel offset (K0108), power leg 
elevation system (E1010), upholstered foam seat cushion (K0669), special seat foam (K0108), curved sheet 
metal pan back (K0108), upholstered foam back (K0669), and special back foam (K0108).  
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that you cannot walk and 
need to be able to get around and do things.  The Plan denied your request. The Plan says  the records do not 
show that the use of the power operated device coded K0899 is reasonable and necessary.  The Plan also says that this device has not been found to meet the definition of a specific power operated 
vehicle/ power wheelchair.  
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 durable medical equipment (DME). 
Our physician reviewer found the documentation available for review does not support that you require a 
power mobility device to accomplish mobility related self-care tasks in the home. There is no indication you 
are unable to use an alternative assistive device. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Big Bounder 600 power wheelchair (K0899), increase 
maximum user weight to 700 pounds (K0108), power seating system, tilt only (E1002), extra heavy duty power 
seating upgrade (K0108), power seating system booster (K0108), custom rear wheel offset (K0108), power leg 
elevation system (E1010), upholstered foam seat cushion (K0669), special seat foam (K0108), curved sheet 
metal pan back (K0108), upholstered foam back (K0669), and special back foam (K0108).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided December 15, 2022, to 
December 23, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the full length of stay was medically 
necessary. The Plan denied your request. The Plan says that observation services would have been more 
appropriate. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee had cellulitis with severe sepsis with acute kidney injury upon admission; 
therefore, the enrollee's inpatient admission was expected to cross two 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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided December 15, 2022, to December 23, 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 provided from January 3, 2023, to 
February 1, 2023. 
 You asked the Plan to pay for the home health services. You say that your organization has been a Medicare-
certified provided since July of 2022. 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 January 3, 2023. The NOA was not received by the Plan until February 3, 
2023. 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 January 3, 2023, to February 1, 2023.