Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on August 26, 2022, billed with 
code 77080. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim has not been billed with a valid 
diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that contractors will deny claims for screening tests 
when coded without a valid diagnosis code from the local lists of valid diagnosis codes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services provided have not been met. This claim has not been billed with a valid diagnosis code for these services. Therefore, we decided that the Plan does not have to pay for imaging services 
provided on August 26, 2022, billed with code 77080.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 1, 2022, to 
November 30, 2022. 
 You asked the Plan to pay for the home health services. You say that you billed this claim correctly. 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 October 2, 2022. The NOA was not received by the Plan until January 5, 
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 services provided 
from November 1, 2022, to November 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71275-26-76 billed for date of service 
December 29, 2022.  
 
You asked the Plan to pay for procedure code 71275-26-76. You say that the claim is billed correctly and 
should be paid The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 71275-26-76 is 1. The MAI value for this code is 3. You billed 2 units of 
this code, exceeding the MUE. You did not provide all the required evidence showing that the excess units 
were actually provided, were correctly coded, and were medically necessary. Based on this information, we 
decided that Medicare rules for coverage of procedure code 71275-26-76 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 71275-26-76 billed for date of service December 
29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 25, 2022, to 
April 23, 2022. 
 You asked the Plan to pay for the home health services. You say that you have provided the required NOA and 
pricer information. The Plan denied your request. The Plan says the NOA was not received timely. As such, 
this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 24, 2022. The NOA was not received by the Plan until April 27, 
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 services provided 
from March 25, 2022, to April 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barotism Neo System (0266T). 
 
You asked the Plan to pre-approve a Barotism Neo System. You say that the device is FDA approved. The Plan 
denied your request. The Plan says this procedure is considered experimental and investigational for the 
treatment of heart failure. Only medical necessary procedures are a covered benefit. 
 
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 Barotism Neo System. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Barostim Neo system is an electronic pulse generator implanted underneath the 
clavicle with a lead tunneled under the skin to the carotid sinus in the neck. The pulse generator delivers 
electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors of one of the carotid arteries. In 
August 2019, the FDA approved the system for use in enrollees with refractory heart failure who remain 
symptomatic despite treatment with guideline-directed medical therapy, are NYHA Class III, have an ejection 
fraction less than 35%, and are not candidates for bi-ventricular pacing. This was based on a clinical study 
demonstrating improvement in normal daily activities, distance walked, quality of life, and improved cardiac 
levels biomarker levels. There remains an absence of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of Barostim Neo in enrollee management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Barotism Neo System have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barotism Neo System (0266T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 18, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement in place which indicates that these tests are included in the dialysis rate. The Plan denied 
your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
18, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 3, 2022, 
to December 15, 2022. 
 
You asked the Plan to pay for the home health services as billed. 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 December 3, 2022, to 
December 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory test (0241U) provided on February 20, 2023. 
 
You asked the Plan to pay for the laboratory test. You say that this test was medically necessary and is 
supported in the medical record. 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 test 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test (0241U) 
provided on February 20, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a video capsule endoscopy (91110). 
 
You asked the Plan to pre-approve a video capsule endoscopy. You say that you want the Plan to approve this 
service. The Plan denied your request. The Plan says Medicare criteria for medical necessity has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that use of wireless capsule endoscopy is indicated 
only if EGD and colonoscopy has been done within the past 12 months and failed to identify a bleeding source.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a video capsule endoscopy have not been met. Specifically, the medical records show that the 
enrollee has not had an EGD or colonoscopy within the past 12 months. Therefore, we decided that the Plan 
does not have to pre-approve a video capsule endoscopy (91110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued coverage for a portable oxygen concentrator. 
 
You asked the Plan to pre-approve portable oxygen concentrator. You say that you are appealing this denial. 
The Plan denied your request. The Plan says the Plan has covered 36 months of rental for this equipment, so 
the vendor is required to provide contents and services for months 37 to 60 of the rental period. 
 
The Plan must follow Medicare rules. Medicare rules say that there is no further payment for oxygen 
equipment after 36 rental payments have been made.  
 
We looked at the file and Medicare rules. The Plan is not responsible for further coverage of the oxygen 
equipment, the equipment vendor should continue to provide the equipment without charge. Based on this 
information, we decided that Medicare rules for coverage of portable oxygen concentrator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve continued coverage for a portable oxygen 
concentrator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee is medically stable and does not need physician supervision three 
times a week in the IRF. There are no acute rehab nursing needs documented. The enrollee does not need 
specialized and intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week 
with multidisciplinary approach in an IRF. She needs routine physical therapy and occupational therapy. The 
documentation does not support the necessity for this admission. The documentation does not support necessity 
for admission to an IRF. The complexity of the enrollee's nursing, rehab, and medical, needs (combined 
complexity) does not require an acute hospital inpatient rehab stay with an interdisciplinary approach to 
rehabilitative care. The enrollee's rehab needs can be safely provided in an alternate and low intensity setting 
such an in a skilled nursing facility (SNF) or in home with therapies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to go to an inpatient rehab to get stronger 
and return to being independent. The Plan denied your request. The Plan says the services you need can be 
provided safely in another setting such as a skilled nursing facility, home with home health services or home 
with outpatient therapy.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the records provided you do not have complex or intensive rehabilitation 
needs. IRF criteria is not met 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 24, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that the enrollee expected to have the same 
coverage when switching from traditional insurance to Medicare. The Plan denied your request. The Plan says 
this service is not covered when provided OON. 
 
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 the laboratory services provided on March 24, 
2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology, gross and microscopic examination 
(88307) and special stain including interpretation and report (88313) provided on November 25, 2022, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the pathology services. You say that you believe that the pathology service 
provided is medically necessary for treatment of the enrollee's medical condition. The Plan denied your request. 
The Plan says enrollees must receive their medical services from an in-network provider with the exception 
being urgent or emergent services. Non-emergent services with non-contracted providers require prior 
authorization before services being rendered.  
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 the surgical pathology, gross and microscopic 
examination (88307) and special stain including interpretation and report (88313) provided on November 25, 
2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from December 1, 2022, to 
December 30, 2022. 
 You asked the Plan to pay for the home health services. You say that this claim was billed correctly. 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 October 2, 2022. The NOA was not received by the Plan until January 5, 
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 1, 2022, to December 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  a pneumatic compression device (E0675) provided 
September 15, 2022, to October 4, 2022. 
 
You asked the Plan to pay for  a pneumatic compression device. You say that you have outlined how this 
enrollee's medical necessity actually meets the guidelines that qualify for coverage. 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. Therefore, we decided that the Plan does not have to 
pay for  a pneumatic compression device (E0675) provided September 15, 2022, to October 4, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary for the enrollee's recovery. The Plan denied your request. The Plan says the requested admission to a 
SNF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not 
have documented skilled therapy needs. The enrollee is ambulating more than 100 feet. Daily skilled services 
are not required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees care needs are custodial and intermittent, and can, as a practical matter, be provided at a lower level 
of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you are appealing this denial. The Plan denied your 
request. The Plan says a ventilator is not covered for this purpose and your needs could be met by a bilevel 
positive airway pressure (BiPAP) device. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.