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

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided February 
9, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the DVT unit prescribed after the 
enrollees surgery was at the request of the physician due to medical necessity to prevent blood clots and aid in healing at the enrollees home.  The Plan denied your request. The Plan says pneumatic compression device is 
not covered by Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
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. The enrollee used the equipment in the facility during 
and/or after surgery. Payment for this service would have been included under the facility claim. Payment for 
this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that 
the Plan does not have to pay for a pneumatic compression device (E0676) provided February 9, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (97140) provided on October 15, 2021. 
 
You asked the Plan to pay for the therapy services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the billed code is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 97140 is not supported in the medical record. Specifically, this service is included in 
CPT code 29581 which was also billed. Based on this information, we decided that Medicare rules for coverage 
of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy 
services (97140) provided on October 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided in the hospital from  
March 24, 2023, to March 27, 2023.  
 
You asked the Plan to pay for the medication. You say that insulin shots administered by the hospital should be 
covered since it will not be covered by their Part D prescription drug plan. 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 pay for self-administered drugs provided 
in the hospital from March 24, 2023, to March 27, 2023.   
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 29, 2023, to 
March 29, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you were originally told that the 
patient had other insurance, and that other insurer doesn't require NOAs. You stated that you have now 
submitted the NOA and would like the claim to be processed. 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 January 29, 2023, to 
March 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that it is medically necessary for the enrollee to 
use home ventilation to prevent hospitalization. The Plan denied your request. The Plan says the enrollee does 
not meet criteria for approval of a ventilator. 
 
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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD with 
associated complications from empyema and decortication and has chronic respiratory failure. Documentation 
does not support failure of bilevel positive airway pressure (BIPAP), in fact, the enrollee is compliant and feels 
better with current therapy, hence, not failure of BIPAP. The enrollee does not meet requirements for home 
ventilation. Adequate ventilation is documented and achieved with BIPAP therapy. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 9, 2023, to 
January 11, 2023. 
 You asked the Plan to pay for the home health services. You say that you are a Medicare-certified provider and 
no authorization is required. 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 December 10, 2022. 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 9, 2023, to January 11, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for computed tomography, bone mineral density study provided on  
March 13, 2023. 
 
You asked the Plan to pay for computed tomography, bone mineral density study. You say that the services 
were medically necessary. The Plan denied your request. The Plan says that this service does not meet the 
coverage requirements in the applicable Local Coverage Determination (LCD) or National Coverage 
Determination (NCD). Related services performed in connection with the denied procedure are also not 
covered. 
 
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 Medicare rule, a Plan rule or a coding 
rule to substantiate their denial. Therefore, we decided that the Plan has to pay for computed tomography, bone 
mineral density study provided on March 13, 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: Favorable

 
We decided that the Plan has to pre-approve a non-invasive ventilator (NIV) (E0466x3 units). 
 
You asked the Plan to pre-approve a NIV. You say that the enrollee has a significant restrictive process due to 
the insufficient ventilation caused by obesity hypoventilation syndrome. The NIV is medically necessary. The 
Plan denied your request. The Plan says that the request for a NIV is 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 a NIV. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the enrollee does have obesity hypoventilation 
syndrome (OHS) and associated chronic respiratory failure with both hypercapnia and hypoxemia. The enrollee 
has been on and is being treated with Astral with intelligent volume-assured pressure support (iVAPS). The 
enrollee is compliant and shows improvement. It would not be best practice to withdraw or stop this therapy, as 
it is working well and treating the enrollee. Hence, she meets criteria for continued home ventilation with 
iVAPS via Astral. 
 
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 NIV have been met. Therefore, we decided that the Plan has to pre-approve a 
non-invasive ventilator (NIV) (E0466x3 units).  
 
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 services provided on March 13, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. 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 services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on March 13, 2023.
Appeal type: Lab
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 24, 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 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 26, 2023, billed 
with codes 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, & 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary. 
The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 26, 2023, billed with codes 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 
& 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory polymerase chain reaction (PCR) panel 
provided on February 16, 2023, and billed with codes 87631 and 87541. 
 
You asked the Plan to pay for the respiratory PCR panel. You say that this testing was medically necessary.  
The Plan denied your request. The Plan says this test 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 respiratory PCR panel have not been 
met. Therefore, we decided that the Plan does not have to pay for the respiratory polymerase chain reaction 
(PCR) panel provided on February 16, 2023, and billed with codes 87631 and 87541.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from December 9, 2022, to 
January 7, 2023. 
 You asked the Plan to pay for the home health services. You say that you attempted to submit the NOA timely, 
but it was rejected due to a Tax ID issue. 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 December 9, 2022. The NOA was not received by the Plan until February 
28, 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 December 9, 2022, to January 7, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a regadenoson injection provided on 
October 18, 2022. 
 
You asked the Plan to waive the coinsurance for a regadenoson injection. You say that you have never had to 
pay for this service before. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Part B covered chemotherapy drugs and other Part B covered drugs. 
 
You have been asked to pay 20% coinsurance for a regadenoson injection. This item/service falls within the 
Part B covered chemotherapy drugs and other Part B covered drugs benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is $49.08 ($245.38 allowed 
amount x 20% = $49.08 rounded up). Therefore, we decided that the Plan does not have to waive the 
coinsurance for a regadenoson injection provided on October 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant surgeon services provided on June 9, 2022. 
 
You asked the Plan to pay for assistant surgeon services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says this provider does not accept Medicare. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for assistant surgeon services provided 
on June 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dermatology procedure (11646), tissue transfer 
(14040), and skin graft procedure to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a dermatology procedure, tissue transfer, and skin graft procedure. You say 
that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that 
are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a dermatology procedure (11646), tissue transfer (14040), and skin graft procedure to be provided by an out-of-
network (OON) provider.
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, 
full arm (E0668) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a pneumatic compressor and a full arm segmental pneumatic appliance to be 
provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan 
says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not 
been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. 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, full arm (E0668) to be provided by an out-of-network 
(OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) heart with quantitative 
evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve a heart CT calcium score scan. You say that the services are necessary. The 
Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered 
service and will be denied as not medically necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heart CT calcium score scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) heart with quantitative evaluation of coronary calcium 
(75571).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Detect test (0012M) provided September 28, 
2022. 
 
You asked the Plan to pay for the laboratory testing. You say that you are appealing the denial of coverage or 
the Cxbladder Detect test. The Plan denied your request. The Plan says the Cxbladder Detect test remains 
unproven. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the Cxbladder Detect test (0012M) provided September 28, 2022.