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 (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. 
The Plan denied your request. The Plan says this is not a covered device. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the home ventilator. You say that the enrollee needs the ventilator due to 
severe chronic obstructive pulmonary disease (COPD) and is currently on a BiPAP that is not helping with 
their condition.  The Plan denied your request.  The Plan says a home ventilator is not medically necessary for the enrollee because their needs can be met with 
an alternative device such as a BiPAP device with average volume-assured pressure support (AVAPS). 
 
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 reviewer says 
that the home ventilator is not medically necessary. Our physician reviewer found the enrollee does have 
COPD with chronic respiratory failure but has yet to attempt BiPAP therapy. It would be best practice to 
attempt to upgrade to BiPAP from CPAP therapy and re-revaluate response. There is no documented failure of 
BiPAP and hence, does not meet criteria to step up to a home ventilator. Therefore, no home ventilator 
indicated per documentation provided. 
 
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 a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system (E0466), a water chamber 
(A7046) and a humidifier(E0562). 
 
  You asked the Plan to pre-approve a home ventilator system (E0466), a water chamber (A7046) and a 
humidifier(E0562). You say that denying authorization or downgrading to a lesser device would have 
devastating consequences. You say that while other devices can provide a similar mode called AVAPS, they 
are not equipped with the same pressure and flow ranges or features necessary for the enrollee's need for 
advanced ventilation.  The Plan denied your request. The Plan says a home ventilator is not medically 
necessary for this patient because their needs can be met with an alternative device such as a BiPAP device 
with average volume-assured pressure support (AVAPS).  
 
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 a home ventilator system (E0466), a 
water chamber (A7046) and a humidifier(E0562). Our reviewer says that a home ventilator system (E0466), a 
water chamber (A7046) and a humidifier(E0562) is not medically necessary. Our physician reviewer found that 
the documentation and data does not support a home ventilator. The enrollee can be treated initially with a 
BiPAP or BiPAP with AVAPS, as there is no documented failure of either 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 a home ventilator system (E0466), a water chamber (A7046) and a 
humidifier(E0562) have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
home ventilator system (E0466), a water chamber (A7046) and a humidifier(E0562).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. You say that this is medically necessary. The 
Plan denied your request. The Plan says that this does not meet the criteria for coverage. 
 
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 epidural steroid injections. Our 
reviewer says that the service is medically necessary. Our physician reviewer found the patient meets all the 
criteria of the LCD. Therefore, the procedure is 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 epidural steroid injections have been met. Therefore, we decided that the Plan 
has to pre-approve epidural steroid injections.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95937-26 and 95955-26 billed for date of 
service April 19, 2023.  
 
You asked the Plan to pay for the billed services. You say that intraoperative monitoring is the standard of care. 
The Plan denied your request. The Plan says the billed codes are not supported. 
 
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 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method We find that CPT code 95937-26 is not supported. CPT 
code 95937 was billed for train of four testing. Train of Four Testing does not fit the criteria set by CMS and 
Insurance Carriers for CPT 95937. There is no separate code for Train of Four Monitoring, therefore, it would 
be inappropriate to bill the Neuromuscular Junction Testing code for Train of Four Monitoring. 
 
The CPT Code Manual definition of code 95955 is electroencephalogram (EEG) during non-intracranial 
surgery (e.g., carotid surgery). We find that CPT code 95955-26 is not supported. The medical records do not 
include a written report for this diagnostic testing. Based on this information, we decided that Medicare rules 
for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 95937-26 and 95955-26 billed for date of service April 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prosthetic eye (V2623) provided on May 24, 2023. 
 
You asked the Plan to pay for procedure code V2623. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says per claim review history, a different provider 
previously billed code V2623 for date of service June 14, 2022, which is within the previous 5 years. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement durable medical equipment is 
covered in the case of irreparable damage or when the equipment has exceeded the reasonable lifetime period 
of five years.  
We looked at the file and Medicare rules. The file shows that the enrollee's prosthetic eye, billed with code 
V2623-LT, was previously paid less than five years from the date of service at issue. The current prosthetic 
was not documented as being irreparably damaged or exceeding the reasonable lifetime period of five years. 
Therefore, we decided that the Plan does not have to pay for the prosthetic eye (V2623) provided on May 24, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150, 87324, 87500) provided on June 20, 
2023. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT codes 87150, 87324, & 87500 are not supported in the medical record. Specifically codes 
87324, & 87500 are included in code 87506. Code 87150 is included in code 87500. Multiple unbundled codes 
were submitted for a single panel. Based on this information, we decided that Medicare rules for coverage of 
the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(87150, 87324, 87500) provided on June 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker brakes provided on August 19, 2022. 
 
You asked the Plan to pay for the walker brakes. You say that the item should be covered. The Plan denied 
your request. The Plan says this is an item of convenience. 
 
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 pay for the walker brakes provided on August 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 8, 2023. 
 
You asked the Plan to pay for the lab services. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dual rollator/transport wheelchair. 
 
You asked the Plan to pre-approve wheelchair. You say that you are appealing this denial. The Plan denied 
your request. The Plan says you were provided with an ultralight wheelchair in March 2021 which is still 
within its reasonable useful lifetime. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
The item being requested shows to be for replacement of an identical or nearly identical item, due to wear. The 
case file shows that the existing equipment is less than 5 years old. This means that replacement of this 
equipment due to wear is not covered at this time. Therefore, we decided that the Plan does not have to pre-
approve a dual rollator/transport wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test (81479) provided January 18, 2023. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process.  
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test (81479) provided January 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) (64484) at L5-
S1. 
 
You asked the Plan to pre-approve the repeat ESI. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the records do not show that the first injection at L5-S1 provided any 
relief. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI may be considered medically reasonable 
and necessary when the medical record documents that the first injection provided at least 50% of sustained 
improvement in pain relief for three months. 
 
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 repeat ESI. Our reviewer says that 
the requested repeat ESI is not medically necessary. Our physician reviewer found the previous L5-S1 epidural steroid injection provided no pain relief.  Therefore, the reviewer found that the request for a repeat ESI is not 
medically reasonable or 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 repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI) (64484) at L5-S1.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 29, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 29, 2023.
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 February 2, 2023, and billed with codes 874801 x3. 
 
You asked the Plan to pay for the urine PCR panel. 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 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 February 2, 2023, and billed with codes 874801 x3.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on October 17, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory service 
provided on October 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve a bone marrow aspirate. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of 
spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 

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 a bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no specific indication provided to support the request for bone marrow 
aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to 
support the use of bone marrow aspirate for this enrollee's medical condition. No compelling rationale is 
presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone marrow aspirate (20939).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comfort shoes provided on November 29, 2022. 
 
You asked the Plan to pay for the comfort shoes. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the comfort shoes 
provided on November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 22600, 22614, and 22843 for date of service 
May 31, 2023. 
 
You asked the Plan to pay for procedure codes 22600, 22614, and 22843. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
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 codes 22600, 22614, and 22843 are not supported in the medical record. Specifically, the 
submitted medical records do not indicate that arthrodesis, posterior or posterolateral technique, single 
interspace; cervical below C2 segment was performed; therefore, code 22600 is not supported. The submitted 
medical records do not indicate that arthrodesis, posterior or posterolateral technique, single interspace; each 
additional interspace was performed; therefore, code 22614 is not supported. The submitted medical records do 
not indicate that Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments was performed; therefore, code 22843 is not supported. 
Based on this information, we decided that Medicare rules for coverage of procedure codes 22600, 22614, and 
22843 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 22600, 
22614, and 22843 for date of service May 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 22, 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 that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on June 22, 2023.