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

 
We decided that the Plan does not have to pay for the duplex scan of the extremity veins (procedure code 
93971) provided on February 8, 2023. 
 
You asked the Plan to pay for the duplex scan. You say that the appropriate diagnosis codes were used. The 
Plan denied your request. The Plan says diagnosis codes R22.41 and R22.42 should not be billed together if 
there is a bilateral diagnosis code (R22.43) available. 
 
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 93971 is Duplex scan of extremity veins including 
responses to compression and other maneuvers; unilateral or limited study. 
 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the duplex scan. Our reviewer says that the criteria was not 
met. Our reviewer found that the medical record documents localized swelling, mass and lump in left and right 
lower limb. In this case, a more appropriate diagnosis code would be reported. Therefore, this claim denied 
correctly as diagnosis was incorrectly reported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the duplex scan have not been met. Therefore, we decided that the Plan does not 
have to pay for the duplex scan of the extremity veins (procedure code 93971) provided on February 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (33289 and C2624). 
 
You asked the Plan to pre-approve the device. You say that the device is medically necessary. The Plan denied 
your request. The Plan says  the CardioMEMS device at this point should only be approved for patients 
enrolled in a clinical trial. The Plan states there is no indication that this enrollee is enrolled in a clinical trial of 
the device. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical 
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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device (33289 and C2624).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
  You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the request 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 daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services (71046-26) provided on January 3, 
2023. 
 
You asked the Plan to pay for the service. You say that the claim is billed correctly. The Plan denied your 
request. The Plan says  code 71046 is not supported, and the Plan says the diagnosis is inconsistent with the 
procedure. 
 
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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the service. Our reviewer found the documentation submitted 
was reviewed and does not meet criteria. The diagnosis does not support service billed. Codes 71045, 71046, 
71047, and 71048, will be denied if the only diagnosis on the claim is for lung cancer screening or nicotine 
use/dependence.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pay for the imaging services (71046-26) provided on January 3, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 81240, 81328, and 81241 rendered on October 16, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the documents do not support the services 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 
the denied codes is: 
 
Current Procedural Terminology (CPT) 81240: F2 (prothrombin, coagulation factor II) (eg, hereditary 
hypercoagulability) gene analysis, 20210G>A variant 
 
Current Procedural Terminology (CPT) 81241: F5 (coagulation factor V) (eg, hereditary hypercoagulability) 
gene analysis, Leiden variant 
 
Current Procedural Terminology (CPT) 81328: SLCO1B1 (solute carrier organic anion transporter family, 
member 1B1) (eg, adverse drug reaction), gene analysis, common variant(s) (eg, *5) 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found the laboratory report includes normal 
results for all of the codes. Therefore, the denied codes are supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
procedure codes 81240, 81328, and 81241 rendered on October 16, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that additional SNF care is needed. You said that the 
enrollee is not ready to be discharged. The Plan denied your request. The Plan says the requested service is not 
medically necessary because the enrollee has no daily skilled therapy or skilled nursing needs. 
 
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 daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
 At the time of admission, the enrollee required skilled rehab services to improve function due to weakness and 
deconditioning.  There were no skilled nursing needs.  As of last covered day, the enrollee did not require any 
skilled nursing or rehab services on a daily basis.  He was not expected to make measurable gains within a 
reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or 
self-care tasks.  The enrollee did not require skilled therapy to establish a safe and effective maintenance 
program.  As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a 
skilled level of care as of July 24, 2023. The enrollee did not have any parental medications, complex wound 
care or nutrition given via a feeding tube.  The enrollees function was at or near his new baseline level of 
function and he could be discharged to a lower level of care for further services.  As of July 24, 2023, the 
enrollee required custodial services.  
 
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 continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a new patient office or other outpatient visit provided on June 28, 2022. 
 
You asked the Plan to pay for a new patient office or other outpatient visit. You say that the patient was seen 
for Panniculitis with an office visit. The Plan denied your request. The Plan says that the provider does not 
meet the criteria to be billing 99205. 
 
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 coding rule or a Medicare rule to 
substantiate their denial. Therefore, we decided that the Plan has to pay for a new patient office or other 
outpatient visit provided on June 28, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you the full billed charges for emergency treatment 
including x-rays, a reduction procedure, anesthesia and a cast provided on December 21, 2022. 
 
You asked the Plan to reimburse you the full billed charges for the emergency treatment including x-rays, a 
reduction procedure, anesthesia and a cast. You say that you should be covered fully for worldwide emergency 
care with a $90 copayment. The Plan denied your request. The Plan says that the Plan will reimburse for 
covered out-of-network emergency and urgent care services outside of the U.S. and its territories at Original 
Medicare reimbursement rates. You will be responsible for any costs above what Original Medicare would pay, 
less any cost-sharing for the services you received. You were correctly reimbursed for the urgent/emergent 
services in accordance with the Original Medicare Reimbursement rate. 
 
The Plan contract says the Plan will reimburse for covered out-of-network emergency and urgent care services 
outside of the U.S. and its territories at Original Medicare reimbursement rates. You will be responsible for any 
costs above what Original Medicare would pay, less any cost-sharing for the services you received.  
 
We looked at the file and the Plans rules. The file shows that you were correctly reimbursed for the 
urgent/emergent services in accordance with the Original Medicare Reimbursement rate. Therefore, we decided that the Plan does not have to reimburse you the full billed charges for emergency treatment including x-rays, a 
reduction procedure, anesthesia and a cast provided on December 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 10, 2023. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the Plan requires utilization of network providers when possible and 
available and requires authorization for certain services. No medical necessity for an out-of-network provider 
such as an urgent or an emergent situation that has been documented.   
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on January 10, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for diagnostic testing provided on October 16, 2021. 
 
You asked the Plan to pay for the diagnostic testing. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that the charges for or in connection with services or supplies that are, 
as determined by us, considering to be experimental or investigational are excluded from coverage under the 
member's plan. As well as 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 diagnostic testing provided 
on October 16, 2021.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthotic device (L8702). 
 You asked the Plan to pre-approve the orthotic device. You say that you are appealing the denial of the MyoPro 
orthotic device. The Plan denied your request. The Plan says this item is considered experimental and 
investigational. There is insufficient evidence of its effectiveness in those with stroke and hemiparesis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 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. 
 
We looked at the file and Medicare rules. 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. 
Based on this information, we decided that Medicare rules for coverage of the orthotic device have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro orthotic device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve addition, endoskeletal, knee-shin system, stance flexion 
feature (L5845). 
 
You asked the Plan to pre-approve the knee-shin system, stance flexion feature. You say that these additional 
features are extremely Important in producing a balanced and efficient gait throughout ambulation. Please 
reconsider the decision to deny the prosthetic codes. The Plan denied your request. The Plan says code L5845 is bundled into already approved addition, endoskeletal knee-shin system, polycentric, hydraulic swing phase 
control, mechanical stance phase lock (L5814). 
 
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 L5845 
is a column II code to column I code L5814. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pre-approve addition, endoskeletal, knee-shin 
system, stance flexion feature (L5845).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery pack for continuous positive airway pressure 
(CPAP) device (E1399). 
 
You asked the Plan to pre-approve a CPAP battery pack. You say that you need the battery pack to have apnea 
treatment when she loses electricity in order to avoid hospitalizations.  The Plan denied your request. The Plan 
says this service is not covered by Medicare. 
 
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 pre-approve a battery pack for continuous positive airway pressure 
(CPAP) device (E1399).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on December 6, 2022. 
 
You asked the Plan to pay for the ambulance services . You say that the claim should be paid. The Plan denied 
your request. The Plan says no transport happened. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 6, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on December 6, 
2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve nerve device to place in the chest area to stimulate the enrollee's 
breathing (phrenic nerve stimulator) (0424T). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that the request for an implantable phrenic nerve stimulator for the 
treatment of central sleep apnea 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 the service. Our physician reviewer 
found the enrollee has a diagnosis of central sleep apnea; therefore, a treatment with phrenic nerve stimulator 
may benefit based on review of studies. 
 
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 service have been met. Therefore, we decided that the Plan has to pre-
approve nerve device to place in the chest area to stimulate the enrollee's breathing (phrenic nerve stimulator) 
(0424T).  
 
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 hydration infusion services provided on September 29, 2022. 
 
You asked the Plan to pay for hydration infusion services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says with the information we have, we cannot determine how the 
member came to the servicing provider, whether the services were performed as billed, or whether the services 
are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of hydration infusion services have been 
met. Therefore, we decided that the Plan does not have to pay for hydration infusion services provided on 
September 29, 2022.