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

 
We decided that the Plan does not have to reimburse you for the nasal interface (mask or cannula type) with or 
without head strap (A7034) water chamber for humidifier (A7046) and monitoring feature/device, stand-alone 
or integrated, any type, includes all accessories (A9279) purchased January 23, 2023. 
 
You asked the Plan to reimburse you for the continuous positive airway pressure (CPAP) supplies. You say 
that you did not want to risk getting pneumonia and avoid hospitalization and you had to purchase these items 
yourself. The Plan denied your request. The Plan says the CPAP supplies were purchased from a provider who 
does not participate with Medicare 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the nasal interface (mask or 
cannula type) with or without head strap (A7034) water chamber for humidifier (A7046) and monitoring 
feature/device, stand-alone or integrated, any type, includes all accessories (A9279) purchased January 23, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on August 17, 2021, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for genetic testing. You say that this testing has been determined to be reasonable 
and necessary for the management of the enrollee's condition. The Plan denied your request. The Plan says this 
provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan. 
 
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 genetic testing provided on August 17, 2021, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Osteogenesis stimulator (E0747). 
 
You asked the Plan to pre-approve the Osteogenesis stimulator. You say that the service is medically 
necessary. The Plan denied your request. The Plan says records do not show that it has been 9 months since the 
enrollee's fusion surgery. 
 
The Plan follows Medicare rules. Medicare rules say that the noninvasive stimulator device is covered only for 
the following indications: Nonunion of long bone fractures; Failed fusion, where a minimum of 9 months has 
elapsed since the last surgery; Congenital pseudarthroses; serial radiographs have confirmed that fracture 
healing has ceased for 3 or more months prior to starting treatment with the electrical osteogenic stimulator.  
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 Osteogenesis stimulator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the documentation 
does not reveal evidence of a failed fusion, where a minimum of 9 months has elapsed since the last surgery 
nor evidence of a minimum of 2 serial radiographs with multiple views separated by 90 days indicating that 
fracture healing has ceased.  
 
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 Osteogenesis stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Osteogenesis stimulator (E0747).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99233) provided on December 14, 
2022. 
 
You asked the Plan to pay for subsequent hospital care. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the ICD-10-CM has a coding convention that 
requires the underlying condition be sequenced first, if applicable, followed by the manifestation. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of subsequent hospital care have not been met. Specifically, the claim at issue has been billed with 
F05 as the primary diagnosis code. F05 has a code-first note meaning that the underlying condition must be sequenced first on the claim. Therefore, we decided that the Plan does not have to pay for subsequent hospital 
care (99233) provided on December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service November 2, 
2022.  
 
You asked the Plan to pay for procedure code 99214. The Plan denied your request. The Plan says payment for 
code 99214 is bundled into payment for code 01938. 
 
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 99214 
is a column II code to column I code 01938 with a modifier indicator of 0. The column II code is therefore not payable. 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 99214 billed for date of service November 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from August 1, 2022, to August 
30, 2022. 
 You asked the Plan to pay for home health care. You say that you are appealing this denial. 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 August 1, 2022. The NOA was not received by the Plan until November 11, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health care provided 
from August 1, 2022, to August 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that you are requesting reconsideration of the 
denied scooter. The Plan denied your request. The Plan says that the requested power scooter is not medically 
necessary. 
 
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 a power scooter. Our reviewer says that 
the coverage criteria has not been met. Our physician reviewer found that the enrollee has limited functional 
mobility given her diagnosis of muscular dystrophy. The clinical documentation indicates that she has upper 
and lower extremity weakness and difficulty ambulating with a cane or walker. She also appears to have upper 
extremity weakness and lack of endurance that does not allow her to functionally propel a manual wheelchair. 
She may benefit from a power mobility device. However, there is insufficient documentation indicating that the 
enrollee can safely transfer to and from the requested power scooter as well as safely operate it. There is also a 
lack of documentation indicating that the enrollees home is accessible for the requested power scooter. 
 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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from October 25, 2022, to 
November 3, 2022. 
 You asked the Plan to pay for home health care. You say that you are appealing this denial. 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 September 25, 2022. The NOA was not received by the Plan until 
December 30, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no 
payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for home health 
care provided from October 25, 2022, to November 3, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the evaluation and management services provided on October 28, 2022, 
billed with code 99223. 
 
You asked the Plan to pay for the services provided. You say that this payment should not be included in any 
other procedure.  The Plan denied your request. The Plan says that an appeal review was not performed as the 
time frame was missed. 
 
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. The claim was denied stating the service is included in the global payment for a 
surgical procedure. However, no claim or remittance for the surgical procedure was submitted to verify this. 
The Plan did not make an appeal review decision. As such, we find that the denial is not substantiated.  
Therefore, we decided that the Plan has to pay for the evaluation and management services provided on 
October 28, 2022, billed with code 99223.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97163 billed for September 8, 2022, to 
September 9, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says code 97163 was not billed with the required therapy only modifier. 
 
The Plan must follow Medicare rules. The rules say that outpatient rehabilitation claims must be billed with the 
GN, GO, or GP modifier.  
 We looked at the file and Medicare rules. The file shows that the claim was not billed with the required GP 
modifier. 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 pay for procedure code 97163 billed for 
September 8, 2022, to September 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Prostate Artery Embolization procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this procedure is medically necessary. The Plan 
denied your request. The Plan says this procedure is experimental and non-covered. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found there are only limited studies supporting the safety of this procedure. More research is needed 
to show safety and efficacy. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Prostate Artery Embolization procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4550 billed for date of service August 12, 
2020. 
 
You asked the Plan to pay for procedure code A4550. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code A4550 is considered bundled and 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 procedure code. 
 
We find that procedure code A4550 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code A4550 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4550 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4550 billed for date of service August 12, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99285) provided on January 6, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the global charge. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for the requested services (99285) is included in the global 
surgery payment for the procedure (27760) provided on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for the services (99285) provided on January 6, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a transplant evaluation and related services.  
 
You asked the Plan to pre-approve the transplant related services. You say that you want to appeal this denial. 
The Plan denied your request. The Plan says that the requested transplant work-up is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the transplant related services. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case.   
Our physician reviewer found marijuana use is not a contraindication to kidney transplantation. The reviewer 
found there is no medical reason that using marijuana in and of itself that precludes transplant. Therefore, the 
reviewer found that the transplant related services are medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the transplant related services have been met. Therefore, we decided that the 
Plan has to pre-approve a transplant evaluation and related services.   
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery and inpatient services provided October 13, 
2022, to October 14, 2022. 
 
You asked the Plan to pay for the surgery and inpatient services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable 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, the CPT Code Manual definition of code 27487 is revision of total knee arthroplasty, with or 
without allograft; femoral and entire tibial component. 
 
We find that CPT code 27487 is not supported in the medical record. Specifically, this inpatient procedure was 
billed on the outpatient claim. The claim is not payable as billed. Based on this information, we decided that 
Medicare rules for coverage of the surgery and inpatient services have not been met. Therefore, we decided that 
the Plan does not have to pay for the surgery and inpatient services provided October 13, 2022, to October 14, 
2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services rendered from November 29, 2022, to 
December 2, 2022. 
 
You asked the Plan to pay for these services. You say that you needed isolation due to viral meningitis. The 
Plan denied your request. The Plan says that private rooms are 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. The Plan states that a private room is not covered; however, the file shows that 
you were admitted to the hospital with a need for isolation. The Plan has not provided any documentation to 
support that the private room cannot be covered per Medicare rules. Therefore, we decided that the Plan has to 
pay for the inpatient hospital services rendered from November 29, 2022, to December 2, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Botox. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has Spasmodic torticollis. The documentation does not support that the enrollee has tried and 
failed Dysport or Xeomin. The documentation does not support that Dysport or Xeomin would likely be less 
effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for 
the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bacterial urine culture (87086) provided on November 
14, 2022. 
 
You asked the Plan to pay for the bacterial urine culture. You say that this service was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says this claim was not submitted 
with a diagnosis which supports the medical necessity of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes which support 
the medical necessity of code 87086. Any codes which are not listed are considered not medically necessary for 
code 87086. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the urine culture have not been met. Specifically, this claim was submitted with a diagnosis code which is not among those codes listed as medically necessary and appropriate for this service. Therefore, we 
decided that the Plan does not have to pay for the bacterial urine culture (87086) provided on November 14, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services (A0436-GZ, A0431-GZ) provided on 
October 1, 2022. 
 
You asked the Plan to pay for air ambulance services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these services are automatically denied. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that A/B MACs shall automatically deny claim line(s) items submitted with a GZ modifier. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of air ambulance services have not been met. Specifically, the records provided show that these codes 
were reported with the GZ modifier. Therefore, we decided that the Plan does not have to pay for air 
ambulance services (A0436-GZ, A0431-GZ) provided on October 1, 2022.