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

 
We decided that the Plan has to pay for the supply allowance for non-adjunctive, non-implanted continuous 
glucose monitor identified with code A4239 for date of service March 9, 2023 
 
You asked the Plan to pay for the supply allowance for non-adjunctive, non-implanted continuous glucose 
monitor. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says that we 
are unable to verify the billed charges and the services cannot be considered for reimbursement at this time. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does contain a valid physician order and proof of delivery. Review of the file does not reveal any 
reason that the required documentation is invalid. Therefore, we decided that the Plan has to pay for the supply 
allowance for non-adjunctive, non-implanted continuous glucose monitor identified with code A4239 for date 
of service March 9, 2023  
 
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 pre-approve a hip replacement (27130) with an out-of-area provider. 
 
You asked the Plan to pre-approve a hip replacement with an out-of-area provider. You say that this is 
medically necessary. The Plan denied your request. The Plan says this provider is out-of-network, and the 
services are available in-network. 
 Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
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 hip replacement with an out-of-area 
provider. Our reviewer says that the service is not medically necessary. Our physician reviewer found you had 
radiographic images as well as magnetic resonance imaging of the bilateral hips in California, which would be 
reasonably expected to be ordered by a physician who was treating you, or evaluating you at the very least, for 
bilateral hip pain. The findings on these diagnostic examinations have not changed significantly when 
compared to the radiographic images on August 29, 2023. Therefore, you could have foreseen requiring the 
services prior to leaving your service area. Detailed documentation regarding a trial and failure of recent, 
reasonable, comprehensive, less invasive conservative care measures is not evident. Proceeding with a total hip 
replacement prior to trial and failure of other reasonable less invasive measures is not supported. There are 
limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this 
clinical setting. No compelling rationale is presented, or extenuating circumstances noted to support the 
medical necessity of this request as an exception to guidelines. You note worsening bilateral hip pain; however, 
conservative treatment modalities are typically recommended prior to surgical treatment. Therefore, it would be 
medically reasonable to delay the services for 6 months. 
 
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 hip replacement with an out-of-area provider have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a hip replacement (27130) with an out-of-area provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
on January 30, 2023, through March 23, 2023. 
 
You asked the Plan to pay for the water circulating heat pad with pump. You say that the item was medically 
necessary. The Plan denied your request. The Plan says this item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if code E0215 or E0217 is provided it will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the water circulating heat pad with pump (E0217) provided on January 30, 2023, 
through March 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of LTACH service is correct. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving with current treatment and should only require 
short-term additional acute care hospital services that can safely be provided at the current facility until more 
stable and appropriate for transfer to 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a vacuum system for a lower limb prosthesis. 
 
You asked the Plan to pre-approve vacuum system. You say that Original Medicare approves this component. 
The Plan denied your request. The Plan says that this component is experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve vacuum system. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee's need for this component is adequately described by prosthetist and surgeon notes 
from May to June in a way that more than satisfies general Medicare documentation requirements for L5781. 
As for Plans main arguments centering on its Omnibus Codes policy, which declares this technology to be 
experimental and generally non-covered, we note that all 9 of the Omnibus Codes cited studies reported on the 
benefits of using vacuum suspension in properly selected amputee patients, most with statistically significant 
findings. This renders moot the Plans objections about sample size. The Omnibus Codes frequent refrain that 
more studies are needed seems to set an arbitrary and capricious standard for rigor of evidence that is not 
supported anywhere in Medicare policy, and it is certainly not a valid basis for declaring whole mainstream 
modalities as not medically necessary for all patients regardless of presentation. There is no doubt that Original 
Medicare would cover this request entirely. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vacuum system have been met. Therefore, we decided that the Plan has to pre-
approve a vacuum system for a lower limb prosthesis.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Hypoglossal Nerve Stimulator Implantation 
(Inspire) (64582, C1778, C1787, C1767). 
 You asked the Plan to pre-approve the Inspire implant. You say that this procedure is medically necessary for 
the enrollee's life-threatening medical condition. The Plan denied your request. The Plan says the enrollee does 
not meet all the requirements for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that hypoglossal nerve stimulation for the treatment 
of obstructive sleep apnea is covered when the enrollee's BMI is less than 35 kg/m2. 
 
We looked at the file and Medicare rules. In this case the medical records show that the enrollee's BMI is 
greater than 35 kg/m2. Based on this information, we decided that Medicare rules for coverage of the Inspire 
implant have not been met. Therefore, we decided that the Plan does not have to pre-approve the Hypoglossal 
Nerve Stimulator Implantation (Inspire) (64582, C1778, C1787, C1767).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says admission to an LTACH is not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is receiving acute hospital care, and acute care services have not 
been denied. 
 There are no required medical services identified that are available at the LTACH that are not available at the 
current health care setting being offered by the Plan. Consequently, the requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 
The documentation does not support that an additional 25 days of hospitalization are reasonably expected for 
the enrollee in this case. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service November 8, 
2022. 
 You asked the Plan to pay for procedure code 87640. The Plan denied your request. The Plan says payment for 
code 87640 is bundled into payment for code 87641. 
 
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 87640 is a column II code to column I code 87641. Code 87640 has 
not been billed with an appropriate modifier to bypass the edit. 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 87640 
billed for date of service November 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes E0217 and E0675 billed for dates of service 
December 8, 2022, to December 16, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the items do not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
We find that CPT codes E0217 and E0675 are not supported in the medical record. The records show that the 
items at issue were provided for the prevention of deep vein thrombosis. The items are considered not 
reasonable and necessary. 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 
E0217 and E0675 billed for dates of service December 8, 2022, to December 16, 2022.
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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records do not show complex rehabilitation needs. 
The Plan says that the services needed may be provided safely in a lower level of care.  
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 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 procedure codes 87481, 87500, 87640, 87641, 87651, 87653, 
and 87798 for date of service May 23, 2023. 
 You asked the Plan to pay for procedure codes 87481, 87500, 87640, 87641, 87651, 87653, and 87798. You 
say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes procedure codes 87481, 87500, 87641, 87651, 87653, and 87798 are not supported in 
the medical record. Specifically, there is a more appropriate lab panel code that should be billed when one or 
more codes are included in the same panel. In this case, we have confirmed that code 87640 is a column II code 
to column I code 87641. While code 87640 was billed with modifier -59, the medical records provided do not 
show that the service billed with the -59 modifier is a distinct procedural service. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 87481, 87500, 87640, 87641, 87651, 87653, and 
87798 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87481, 
87500, 87640, 87641, 87651, 87653, and 87798 for date of service May 23, 2023.
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 it is medically necessary. The Plan denied your 
request. The Plan says you do 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for an 
above the knee amputation. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. 
 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker (E0143) provided on March 8, 2023. 
 
You asked the Plan to pay for the walker. You say that this walker was medically necessary. The Plan denied 
your request. The Plan says the provider is not eligible for Medicare coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a walker (E0143) provided on March 8, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limb compression devices billed for date of service 
February 14, 2023. 
 You asked the Plan to pay for the billed services. You say that the device reduces the incidence of deep vein 
thrombosis. The Plan denied your request. The Plan says the services are not 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 looked at the file, and Medicare rules. We find that the pneumatic compression device, E0676, is excluded 
from coverage under the Medicare benefit. Because the base code is not covered, the related accessories, E0673 
and E0667, are also not covered. Based on this information, we decided that Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pay for the limb compression devices billed 
for date of service February 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
on January 11, 2023, through February 6, 2023. 
 
 
You asked the Plan to pay for the water circulating heat pad with pump. You say that the item was medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that if code E0215 or E0217 is provided it will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the water circulating heat pad with pump (E0217) provided on January 11, 2023, through February 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a vasopneumatic compression unit (VCU) (E0650), and 
relates accessories (E0673, E0666, 97760). 
 
You asked the Plan to pay for a VCU and related accessories. You say that the items were medically necessary. 
The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for 
preventative services. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for a vasopneumatic compression unit 
(VCU) (E0650), and relates accessories (E0673, E0666, 97760).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213-25 provided on May 23, 2023. 
 
You asked the Plan to pay for procedure code 99213-25. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 99213-25 is not supported in the medical record. The office visit at issue was billed 
with modifier 25, which is used to report a significant, separately identifiable Evaluation and Management 
(EM) service by the same physician or other qualified health care professional on the same day of a procedure 
or other service. There is no documentation of any significant, separately identifiable evaluation unrelated to 
the treatment provided to the enrollee on this date of service. Therefore, we decided that the Plan does not have 
to pay for procedure code 99213-25 provided on May 23, 2023.