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

 
We decided that the Plan does not have to pay for radiological services provided on February 9, 2023, billed 
with procedure codes 77067 and 77063. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim is billed correctly and should be paid. 
 The Plan must follow Medicare rules. Medicare rules say that the POS code is generally used to reflect the 
actual setting where the beneficiary receives the face-to-face 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. This claim was inappropriately billed with POS 
23 as the bill type on this claim is outpatient 131. Therefore, we decided that the Plan does not have to pay for 
radiological services provided on February 9, 2023, billed with procedure codes 77067 and 77063.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided January 25, 2022, through 
March 17, 2022. 
 
You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the home health services have not been met. The claim was billed 
with an invalid type of bill for a non-participating home health provider, as the type of bill (TOB) on the claim 
is submitted as "323" which is incorrect and should be "329". We find the Medicare rule for payment of this 
January 25, 2022, through January 27, 2022, February 08, 2022, through February 11, 2022, February 16, 
2022, through February 18, 2022, March 15, 2022, through March 17, 2022, claim has not been met. If the 
provider determines that a billing error occurred during the initial submission of the denied claim, the Plan will 
accept a submission of a corrected claim to consider services for payment. Therefore, we decided that the Plan 
does not have to pay for the home health services provided January 25, 2022, through March 17, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for practitioner services provided on February 27, 2023, billed with 
procedure code E2103. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that documentation does not support the billed 
code. 
 
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 E2103 is non-adjunctive, non-implanted continuous glucose monitor or receiver. 
 
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 practitioner services provided. Our reviewer says that 
documentation does support the billed code. Our reviewer found that the medical record includes an invoice for 
glucose monitor, as well as a tracking sheet documenting delivered. 
 
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 practitioner services provided have been met. Therefore, we decided that the 
Plan has to pay for practitioner services provided on February 27, 2023, billed with procedure code E2103.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 8, 2022, 
through December 5, 2022.  
You asked the Plan to pay for the home health services . You say that the claim should be paid. 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.  
 
The claim denied appropriately for because a 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 start of care date result in no payment being 
made for the episode of care. The NOA for this Home Health series of care was not submitted until December 
23, 2022, under the claim, which has a start of care/admission date of June 9, 2022. Therefore, we decided that 
the Plan does not have to pay for the home health services provided from August 8, 2022, through December 5, 
2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Y-90 radiation treatment. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found radioembolization is not outside the 
generally accepted professional medical standards as being safe and effective. For patients with liver-
predominant disease, with no other therapeutic options, who has previously undergone systemic therapy, 
treatment with Y90 radioembolization can be considered medically necessary. Quality of life can be 
substantially improved with liver-directed therapy for this enrollee. Liver directed therapy has a reasonable 
likelihood of preventing (ore delaying) symptomatic progression. The services are therefore reasonable and 
medically necessary 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve Y-90 radiation treatment.  
 
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 a spinal bone growth stimulator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a bone growth stimulator is covered when 
specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not document a failed spinal fusion where a minimum of nine months has elapsed since the last surgery or a multilevel spinal fusion 
surgery or a spinal fusion surgery where there is a history of a previously failed spinal fusion at the same site. 
The criteria for coverage are not met and the services are not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal bone growth stimulator.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service March 26, 
2023, to April 22, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that this was medically necessary care.  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 March 26, 2023, to April 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen equipment provided on March 2, 2023. 
 
You asked the Plan to pay for the oxygen equipment. You say that you billed covered diagnoses on the claim. 
The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that J96.90 has an Excludes1 note in relation to R09.02. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the oxygen equipment have not been met. Therefore, we decided that the Plan does not have to 
pay for the oxygen equipment provided on March 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the use of the Superion spacer has not 
been shown in controlled studies in a Medicare-approved journal to result in long term health benefits in 
patients with lumbar spinal stenosis with radiculopathy. Its use is not supported by current peer-reviewed 
literature. The services are therefore not reasonable or medically necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion spacer.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve TPMT testing. We decided that the Plan does not have to pre-
approve SMN1 testing. 
 You asked the Plan to pre-approve genetic analysis testing. You say that you disagree with the denial. The Plan 
says that the services are not medically necessary. 
 
We decided that the Plan has to pre-approve TPMT testing. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing is covered when specific criteria 
are met. 
 
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 these services. Our reviewer says that 
TPMT testing is medically necessary and SMN1 testing is not medically necessary. Our physician reviewer 
found that the documentation is not adequate regarding concern for spinal muscular atrophy in this enrollee. 
Consequently, the SMN1 testing described by code 81336 is not medically necessary. 
 
The documentation contains results of TPMT genotype testing reported on April 18, 2023. The provider wrote 
on May 4, 2023 that it was medically necessary to have TPMT genotype testing prior to starting treatment, 
stating that any mutations of the gene could lead to decreased clearance of aziothioprine, increasing the risk of 
toxicity. The testing is therefore reasonable and medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TPMT testing have been met. Therefore, we decided that the Plan has to pre-
approve TPMT testing.  
 
We also decided that the Plan does not have to pre-approve SMN1 testing. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing is covered when specific criteria 
are met. 
 
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 these services. Our reviewer says that 
SMN1 testing is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SMN1 testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SMN1 testing. 
 
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 continued use of home ventilator, any type, used 
with non-invasive interface, (e.g., mask, chest shell) (E0466). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that you currently are using 
the Trilogy Evo portable hospital to home ventilator and you are worried you may be billed from the supplier. 
The Plan denied your request. The Plan says  E0466 is denied as not medically necessary. The Plan states they denied A7034, A7030, A7039, E0562, A7037, A7035, as unbundling. The Plan states monthly rental fees 
cover the ventilator and all supplies and services for the device.  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the durable medical equipment (DME). 
Our physician reviewer found you qualify for home bilevel positive airway pressure (BiPAP), but Medicare 
does not cover a home ventilator when used at settings that can be provided with BiPAP. Without compliance 
data, there is no documentation that home BiPAP has failed, and home BiPAP with average volume-assured 
pressure support (AVAPS) has not been tried. The denial is upheld. Codes A7034, A7030, A7039, E0562, 
A7037, A7035, are denied for unbundling.  
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the continued use of home ventilator, any type, used with 
non-invasive interface, (e.g., mask, chest shell) (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rollator walker with brakes. 
 
You asked the Plan to pre-approve a rollator walker. You say that the records provided support the medical 
necessity of the requested item. The Plan denied your request. The Plan says the records provided do not 
support the medically necessary criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 a walker have been met.  Additional information was requested which included clinical records documenting medical necessity and a 
detailed written order indicating the specific Healthcare Common Procedure Coding System (HCPCS) code of 
the requested item. The records show that the Plan made multiple attempts to obtain the additional records 
without success. Therefore, we decided that the Plan does not have to pre-approve a rollator walker with 
brakes.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Koya Dayspring non-pneumatic compression system 
(K1024 and K1033). 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary.  The Plan denied your 
request. The Plan says more research is needed to show the safety and efficacy of this system.  
 
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 items. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this newer device does not have current high-quality evidence from peer-reviewed literature 
showing benefit over other more standard treatments to help support this request at this time. Therefore, due to 
insufficient support made for this request, the Koya Dayspring device will be considered not medically necessary for this enrollee 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 the items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Koya Dayspring non-pneumatic compression system (K1024 and K1033).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on January 7, 2023, billed with 
evaluation and management (EM) code 99223. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is 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 is generally used to reflect the 
actual setting where the beneficiary receives the face-to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. This claim was inappropriately billed with 
POS 21 as the enrollee was registered outpatient on this date of service. Therefore, we decided that the Plan 
does not have to pay for practitioner services provided on January 7, 2023, billed with evaluation and 
management (EM) code 99223.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95076 and A4617 rendered on January 3, 
2023.  
 
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 the records 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 code 95076 is ingestion challenge allergy and clinical 
immunology testing procedures. The definition of code A4617 is mouthpiece. 
 
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 found for code 95076, the 
documentation submitted was reviewed and does not meet criteria. The medical record does not include 
documentation to support ingestion challenge was performed for date of service billed. For 95076, the provider 
performs this test to identify which foods, drugs, or other substances trigger an allergic response in an 
individual. Our review was unable to cite report as this procedure was not found in documentation submitted. 
For code A4617, the documentation submitted was reviewed and does not meet criteria. The provider 
performed spirometry, which a disposable mouthpiece would be used. This is considered supplies and would be 
included in the primary procedure. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 95076 and A4617 rendered on January 3, 2023.