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

 
We decided that the Plan has to pre-approve IDPN therapy. 
 
You asked the Plan to pre-approve IDPN therapy. You say that the enrollee's oral intake is incapable of 
meeting her nutritional needs while balancing the protein losses due to hemodialysis. The Plan denied your 
request. The Plan says that the requested IDPN therapy is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that for parenteral nutrition to be considered reasonable 
and necessary, the treating practitioner must document that enteral nutrition has been considered and ruled out, 
tried and been found ineffective, or that EN exacerbates gastrointestinal tract dysfunction. The enrollee must 
have a permanent impairment. 
 
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 IDPN therapy. Our reviewer says that 
the coverage criteria has been met. Our physician reviewer found that the enrollee has severe protein calorie 
malnutrition that is associated with poor outcomes. The enrollee is unable to meet nutritional demands with 
oral nutrition.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IDPN therapy have been met. Therefore, we decided that the Plan has to pre-
approve IDPN therapy.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service January 22, 
2023.  
 
You asked the Plan to pay for procedure code 99223. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 99223 is bundled into payment for code 
99285. 
 
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 99223 is a column II code to column I code 99285 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 99223 billed for date of service January 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for respiratory pathogen testing provided on October 4, 2022. 
 
You asked the Plan to pay for the respiratory pathogen testing. You say that you have provided medical records 
to support payment. The Plan denied your request. The Plan says this testing is not covered. The Plan must 
follow Medicare rules. Medicare rules say that respiratory pathogen panels with more than 5 respiratory 
pathogens performed are not covered. In this case, the lab reports show that more than 20 different respiratory 
pathogens were tested. Therefore, we decided that the Plan does not have to pay for respiratory pathogen 
testing provided on October 4, 2022.
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 the enrollee needs therapy because of they are 
unable to walk without assistance. The Plan denied your request. The Plan says that the 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 that the clinical documentation shows that the enrollee is near functional baseline 
without any documented inpatient and/or daily therapy goals. From a practical standpoint, the clinical 
documentation does not show that the enrollee requires daily skilled services on an inpatient basis in a skilled 
nursing facility. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy services rendered on December 5, 
2022. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that the documentation supports 
medical necessity. The Plan denied your request. The Plan says an appropriate diagnosis was not billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for medical nutrition therapy services rendered on December 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 29, 
2023 to February 25, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 29, 2023 to February 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 8, 2022. 
 
You asked the Plan to pay for the medical services. You say that the facility did not give you proper insurance 
information. The Plan denied your request. The Plan says you did not timely file this claim. The Plan follows 
Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no 
later than one calendar year after the date of service. The record shows that a claim for the medical services 
was not filed until February 11, 2023. This means that more than one calendar year from the date of service had 
passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for medical services 
provided on February 8, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services rendered from August 4, 2022, to August 24, 
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 this procedure is included in the primary procedure. 
 
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 has not submitted a valid denial. The plan has not substantiated their 
denial reason of 'this procedure is included in the primary procedure. The plan has not specified what primary 
procedure these codes would be bundled to. The denial reason is too broad and vague to verify. Therefore, we 
decided that the Plan has to pay for home health services rendered from August 4, 2022, to August 24, 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: 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 4, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the lab services were 
medically necessary. 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 
4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound polymerase chain reaction (PCR) panel provided 
on January 6, 2023, and billed with codes 87798, 87653, 87651, 87641, 87563, 87529, 87500 and 87481. 
 
You asked the Plan to pay for the wound 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 singled panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the wound PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the wound polymerase chain reaction (PCR) panel 
provided on January 6, 2023, and billed with codes 87798, 87653, 87651, 87641, 87563, 87529, 87500 and 
87481.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on January 14, 2023, billed 
with code 93970. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid place of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code assigned by the 
physician/practitioner shall be the setting in which the beneficiary received the service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiology services provided have not been met. The file shows that the enrollee was an 
inpatient on the date of service. As such, the outpatient POS code 22 is not appropriate. Therefore, we decided 
that the Plan does not have to pay for radiological services provided on January 14, 2023, billed with code 
93970.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroplasty (22511). 
 
You asked the Plan to pre-approve sacroplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met.  
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures are covered under certain circumstances. 
 
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 sacroplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found detailed documentation is not evident 
regarding moderate to severe pain that is worsening, > 25% vertebral body height reduction, kyphotic 
deformity, or a severe impact of VCF on daily functioning. Additionally, there is noted to be lumbar pathology 
that could be causative of significant pain. Therefore, the enrollee does not meet the coverage criteria detailed 
in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroplasty (22511).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found provided records document that the Life2000 home ventilator is being requested for use with very low set tidal volumes (110 to 140 mL) which 
could be provided by a bilevel positive airway pressure (BiPAP) device with average volume assured pressure 
support (AVAPS) and a back-up rate. Provided records do not document trial and failure of a BiPAP device 
with AVAPS and a back-up rate. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99358 billed for date of service February 3, 
2023. 
 
You asked the Plan to pay for procedure code 99358. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 99358 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 99358 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99358 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99358 billed for date of service February 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on December 
14, 2022. 
 
You asked the Plan to pay for the Cxbladder detect test. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder detect test have not been met. Therefore, we decided 
that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on December 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair (K0003RR) and a wheelchair 
component (K0108). 
 
You asked the Plan to pre-approve a lightweight wheelchair and wheelchair component. You say that you are 
requesting reconsideration of the denied authorization. The Plan denied your request. The Plan says that the 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a lightweight wheelchair will not be covered if the 
enrollee does not have mobility deficit that impairs their participation in MRADLs, the enrollees condition can 
be ameliorated by a walker or cane, or the enrollee is not capable of safely propelling the wheelchair. 
 
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 lightweight wheelchair. Our reviewer 
says that the coverage criteria has not been met. Our physician reviewer found that the record does not support 
the enrollee's impairment cannot be addressed with a cane or walker. As the lightweight wheelchair is not 
medically necessary, the requested wheelchair component is not covered. 
 
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 lightweight wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lightweight wheelchair (K0003RR) and a wheelchair component (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services (92012) provided on October 
31, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the specialist visit. You say that you were seen at urgent care due to getting 
shingles by your eye and the urgent care doctor referred you to see the eye specialist due to it being near your 
eye. 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 ophthalmological services (92012) provided 
on October 31, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95941 billed for date of service March 17, 
2023. 
 
You asked the Plan to pay for procedure code 95941. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 95941 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 95941 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 95941 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 95941 billed for date of service March 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on April 28, 2022, to May 16, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration for the services 
provided. 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 office visit provided on 
April 28, 2022, to May 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia billed with code J3490 for date of service 
March 13, 2023 
 
You asked the Plan to pay for code J3490. You say that code J3490 was a medically necessary part of this 
patient's treatment and separate expenses are incurred for this medication. The Plan denied your request. The 
Plan says separate payment cannot be made for this code. 
 
The Plan must follow Medicare rules. Medicare rules say that rules say that if performed to facilitate an 
injection, the use of local anesthesia is included in the global surgery payment and is not separately billable.  
 
In this case, the patient underwent a knee joint injection (code 64450-LT).  As part of the surgery, the provider 
also provided local anesthetic.  This anesthetic was billed with code J3490. Medicare rules are clear that no 
separate payment is made for local anesthetic, regardless of the expense incurred.  You did not bill this drug 
with a modifier to indicate it was separate and distinct from the procedure itself, so no separate payment can be 
made.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code J3490 have not been met. Therefore, we decided that the Plan does not have to pay for local 
anesthesia billed with code J3490 for date of service March 13, 2023