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

 
We decided that the Plan does not have to reimburse you for the combination sit to stand frame/table system, 
any size including pediatric, with seat lift feature (E0637) provided on July 14, 2022. 
 
You asked the Plan to reimburse you for the stair chair. You say that this is medically necessary to help you 
with ambulation issues due to recent fracture. The Plan denied your request. The Plan says this item does not 
serve a medical purpose and therefore is not covered. 
 
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 reimburse you for the combination sit to stand frame/table system, any 
size including pediatric, with seat lift feature (E0637) provided on July 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
April 19, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service April 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
system. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM system. You say that the requested CGM is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for approval of the requested CGM system. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre 2 CGM system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) system.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional transportation trips. You say that you need additional rides for 
several appointments due to your medical condition. The Plan denied your request. The Plan says you have 
exhausted the maximum benefit of 48 one-way trips per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs continued nutritional 
support, fluid removal with dialysis and slow weaning from the ventilator. The Plan denied your request. The 
Plan says based on Medicare guidelines, admission to a Long-Term Acute Care Hospital does not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neck/spine x-ray (CPT 72040), an x-ray of jaw  
(CPT 70100), diagnostic radiology procedures of the head and neck (CPT 70310), a chest x-ray (CPT 71045), a 
swallowing function x-ray (CPT 74230), and an upper gastrointestinal tract x-ray (CPT 74240) provided on 
February 24, 2023. 
 
You asked the Plan to pay for a neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100), diagnostic 
radiology procedures of the head and neck (CPT 70310), a chest x-ray (CPT 71045), a swallowing function 
x-ray (CPT 74230), and an upper gastrointestinal tract x-ray (CPT 74240). You say that the services were 
medically necessary. The Plan denied your request. The Plan says the services were performed at a nursing 
home (via mobile van/portable x-ray), which are denied as an excluded place of service. 
 
The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100), diagnostic radiology procedures of 
the head and neck (CPT 70310), a chest x-ray (CPT 71045), a swallowing function x-ray (CPT 74230), and an 
upper gastrointestinal tract x-ray (CPT 74240) have not been met. Therefore, we decided that the Plan does not 
have to pay for a neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100), diagnostic radiology procedures 
of the head and neck (CPT 70310), a chest x-ray (CPT 71045), a swallowing function x-ray (CPT 74230), and 
an upper gastrointestinal tract x-ray (CPT 74240) provided on February 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 standard power operated vehicle (POV) 
(K0806). 
 
You asked the Plan to pre-approve a Group 2 standard POV. You say that you suffer from obesity, have no 
collegian in your knees, and are unable to stand for long periods of time. You also say that you are constantly 
breaking out in sores from being in bed often and were told that having the electric scooter will help you to 
move around more and help prevent the bed sores. The Plan denied your request. The Plan says there is no 
information that the durable medical equipment would be used to address functional mobility deficits within 
the home. 
 
The Plan must follow Medicare rules. Medicare rules say that if a Group 2 POV is provided it will be denied as 
not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Group 2 standard POV have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Group 2 standard power operated vehicle (POV) (K0806).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on March 27, 2023, and billed with codes 87900, 87799, 87798, 87798, 87640, 87500, 87481, and 
87652. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was medically necessary.  
The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on March 27, 2023, and billed with codes 87900, 87799, 87798, 87798, 87640, 87500, 
87481, and 87652.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on April 27, 2023, and billed with codes 87481, 87482, 87500, 87798, 87652, 87799, and 87640. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on April 27, 2023, and billed with codes 87481, 87482, 87500, 87798, 87652, 87799, 
and 87640.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 29, 
2023, to February 25, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 29, 2023, to February 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on April 28, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on April 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you disagree with the 
denial. The Plan denied your request. The Plan says additional trips would exceed your benefit limit. 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 
We looked at your request, the records in the case file, and the rules. The records show that you have used 
fifty-seven (57) one-way transportation trips out of the allowed sixty (60) one-way trips approved. Once 60 
trips are used, the benefit will be exhausted. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 2, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 2, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve magnetic resonance imaging (MRI). You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. The Plan denied 
your request. The Plan says that the criteria for an MRI have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 magnetic resonance imaging (MRI). 
Our reviewer says that the service is medically necessary. Our physician reviewer found the member carries a 
diagnosis of Mild cognitive impairment (MCI). It is well within standards of practice to perform an imaging 
study of the brain to rule out a formal structural etiology in the evaluation of MCI/dementia. The requested 
service would be reasonable and necessary for the patient 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 magnetic resonance imaging (MRI) have been met. Therefore, we decided that 
the Plan has to pre-approve magnetic resonance imaging (MRI).  
 
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 February 28, 2023, to 
March 13, 2023. 
 You asked the Plan to pay for the home health services. You say that you believe the NOA was sent on March 
1, 2023. 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 February 28, 2023. The NOA was not received by the Plan until June 13, 
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 February 28, 2023, to March 13, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77061 billed for date of service February 13, 
2023. 
 
You asked the Plan to pay for procedure code 77061. You say that 77061 should be paid as billed because it is 
not a duplicate and is supported in the documentation. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 77061 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77061 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77061 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77061 billed for date of service February 13, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on August 10, 2022. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says payment is 
included in the hospital's contracted rate. 
 
The Plan must follow Medicare rules. Medicare rules say that "patient transportation" and is covered as an 
inpatient hospital or CAH service and as a SNF service when the SNF is furnishing it as a covered SNF service 
and payment is made under Part A for that service. 
 
We looked at the file and Medicare rules. In this case, payment for the ambulance services is included in the 
Part A hospital payment. The ambulance services are not separately payable. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided 
that the Plan does not have to pay for the ambulance services provided on August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97598 billed for date of service June 12, 
2023. 
 You asked the Plan to pay for procedure code 97598. You say that that the claim is billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 97598 is bundled into payment for code 
11043. 
 
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 97598 
is a column II code to column I code 11043. 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 code 97598 billed for date of service June 12, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S5000 billed for date of service May 16, 
2022. 
 
You asked the Plan to pay for procedure code S5000. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S5000 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S5000 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S5000 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S5000 billed for date of service May 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99358 billed for date of service January 12, 
2023. 
 
You asked the Plan to pay for procedure code 99358. You say that that the claim is billed correctly and should 
be paid. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 99358 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99358 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99358 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99358 billed for date of service January 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for travel and lodging expenses incurred from April 12, 2023, to 
May 5, 2023. 
 
You asked the Plan to pay for travel and lodging expenses. You say that these travel expenses were necessary 
to receive a second opinion from a doctor who can treat your condition. The Plan denied your request. The Plan 
says these expenses are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that in any circumstance in which a Medicare 
Advantage (MA) plan provides transplant services at a more distant location, the MA plan must provide 
reasonable transportation for the enrollee and a companion to the distant facility, and provide reasonable 
accommodations for the enrollee and a companion while in the distant location for medical care. 
 
We looked at the file and Medicare rules. The travel and lodging expenses at issue were not related to 
transplant services at a distant location. Based on this information, we decided that Medicare rules for coverage 
of travel and lodging expenses have not been met. Therefore, we decided that the Plan does not have to pay for 
travel and lodging expenses incurred from April 12, 2023, to May 5, 2023.