Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services provided from July 10, 2022, to July 13, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this is a correction 
of a previously paid claim. This correction resulted in an overpayment. 
 
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 argues that this is a correction of a previously paid claim and this 
correction resulted in an overpayment. However, the Plan has not provided a valid rationale for denial. Without 
supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to 
pay for the services provided from July 10, 2022, to July 13, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29581 rendered on October 25, 2022. 
 
You asked the Plan to pay for the services. You say that the medical records show this product is effective and 
the notes should be reviewed. The Plan denied your request. The Plan says the medical records do not support 
that the service was separate from the other services performed. 
 
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 29581 is "Application of multi-layer compression 
system; leg (below knee), including ankle and foot." 
 
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 not supported by the medical records. Our reviewer found that the procedure report describes 
wound care with application of compression system to the right lower leg. In this case, the application of 
compression system would be included in the primary procedure, as both were performed on same wound. 
Therefore, the billed modifier XU unusual non-overlapping service is not supported in the procedure report. 
 
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 code 29581 rendered on October 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97206) provided from August 17, 2022, 
to November 10, 2022. 
 
You asked the Plan to pay for the infrared therapy services. You say that the services should be paid. The Plan 
denied your request. The Plan says infrared therapy is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is 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 infrared therapy services have not been met. Therefore, we decided that the Plan does not have 
to pay for the infrared therapy (97206) provided from August 17, 2022, to November 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, 88365, and 88381 
billed for date of service June 13, 2022. 
 You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, 88365, and 88381. The Plan denied 
your request. The Plan says these codes are included in the facility payment and are not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, 
88365, and 88381. This means there is both a professional and technical component for the CPT code(s). In this 
case, an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 
88341, 88342, 88360, 88365, and 88381. Based on this information, we decided that Medicare rules for 
coverage of procedure code 88341, 88342, 88360, 88365, and 88381 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, 88365, and 88381 billed for date 
of service June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service July 18, 
2022. 
 
You asked the Plan to pay for procedure code 36000. You say that you believe this claim should be 
reprocessed. The Plan denied your request. The Plan says procedure code 36000 is considered bundled and not 
separately payable.  
 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 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36000 billed for date of service July 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that a genicular nerve block is medically 
necessary. The Plan denied your request. The Plan says the requested genicular nerve block is experimental.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary in this case.  
Our physician reviewer found that genicular nerve blocks and RFA of the genicular nerves are the subject of 
ongoing clinical trials. It is considered experimental at this time. Therefore, the request is deemed not 
medically reasonable and 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hot tub or hydrotherapy bath. 
 
You asked the Plan to pre-approve a hot tub or hydrotherapy bath. You say that you have completed some 
visits with a hydrotherapy bath. You say that your provider has noticed some good changes in your health. You 
say that you have low back pain. You also say that you have trials different medications, natural herbs, and 
injections with no success. The Plan denied your request. The Plan says a hot tub or hydrotherapy bath is not 
covered as this is a convenience item. 
 
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 hot tub or hydrotherapy bath.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intermittent limb compression device (E0675) and a 
water-circulating heat pad with pump (E0217) provided from August 13, 2022, to September 1, 2022. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says these charges are excluded. 
 
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device (E0675) to treat 
peripheral artery disease is not eligible for reimbursement. Additionally, if E0217 is provided, it will be denied 
as not reasonable and necessary.   
We looked at the file and Medicare rules. These items are not covered by Medicare at this time. 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 an intermittent limb compression device (E0675) and a water-
circulating heat pad with pump (E0217) provided from August 13, 2022, to September 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical dressing provided on September 19, 2022, billed 
with 150 units of code A6196. 
 
You asked the Plan to pay for the dressings as billed. You say that the documentation supports the units billed.  
The Plan denied your request. The Plan says the delivery ticket does not show 150 units were delivered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 150 units of CPT code A6196 are not supported in the medical record. The delivery ticket shows 
that 6 boxes with 10 dressings each were delivered. The definition of A6196 indicates one unit is one dressing. 
Only 60 units of A6196 are supported. Based on this information, we decided that Medicare rules for coverage 
of the dressings as billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
surgical dressing provided on September 19, 2022, billed with 150 units of code A6196.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient genetic testing (0288U) provided on December 
14, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for genetic testing. You say that testing was ordered for the enrollee after the 
ordering physician made a professional determination of medical necessity in order to assess the enrollees risk 
of recurrence. 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 outpatient genetic testing (0288U) provided on 
December 14, 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 the percutaneous lysis of epidural adhesions (62264) 
provided on December 16, 2022. 
 
You asked the Plan to pay for the service. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service is experimental/investigational.  
 
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 pay for the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found iysis of adhesions remains experimental for back pain. More research is needed. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for the percutaneous lysis of epidural adhesions (62264) provided on December 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive 
interface (E0466). 
 
You asked the Plan to pre-approve ventilator. You say that the medical records provided support the necessity 
of the services in dispute. The Plan denied your request. The Plan says the records do not support that this 
request is medically reasonable and necessary. 
 
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 ventilator. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records in this case document a diagnosis of chronic respiratory failure consequent 
to chronic obstructive pulmonary disease. The home ventilator is being requested for use in average volume 
assured pressure support (AVAPS) mode with auto-EPAP (AE) which could be provided by a BiPAP device 
with AVAPS and a back-up rate. The provided records document trial of a BiPAP device but records do not 
document that the device was a BiPAP device with AVAPS and a back-up rate. As stated in the Local 
Coverage Determination (L33800): "Claims for ventilators used to provide CPAP or bi-level CPAP therapy for 
conditions described in this RAD policy will be denied as not reasonable and 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 ventilator have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a home ventilator, any type, used with non-invasive interface (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric Hoyer lift (E0635). 
 
You asked the Plan to pre-approve an electric Hoyer lift. You say that your condition has deteriorated since 
November 2022. You say that an electric Hoyer lift is needed to move you to and from the bed, chair and 
commode several times per day. You say that you previously ordered a standard Hoyer lift from a local 
supplier. You also say that it no longer is suitable for your needs. The Plan denied your request. The Plan says 
the documentation does not support that the enrollee has tried a standard hydraulic lift. 
 
The Plan follows Medicare rules. Medicare rules say that a patient lift is covered if transfer between bed and a 
chair, wheelchair, or commode is required and, without the use of a lift, the beneficiary would be bed confined. 
 
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 an electric Hoyer lift. Our reviewer says 
that the requested electric Hoyer lift is not medically necessary. Our physician reviewer found the provided 
documentation does not include a physical exam supporting a need for this device. The reviewer also found 
that the provided documentation does not support that without a lift you would be bed confined. Therefore, the 
reviewer found that an electric Hoyer lift is not medically reasonable or 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 an electric Hoyer lift have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electric Hoyer lift (E0635).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Simponi Aria (J1602). 
 You asked the Plan to pre-approve Simponi Aria. You say that the requested drug is necessary for the enrollee's 
treatment. The Plan denied your request. The Plan says the enrollee has not tried and failed at least two of the 
preferred drugs, Avsola, Inflectra or Renflexis. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Simponi Aria. Our reviewer says that 
the step therapy criteria have not been met. Our physician reviewer found the provided records do not indicate 
that the enrollee has tried and failed the plan's preferred drugs. The record does not indicate that the enrollee 
has a contraindication to or would have an adverse effect from the plan's preferred drugs. Therefore, the 
reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Simponi Aria have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Simponi Aria (J1602).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies identified with codes A7038, A4604, A7032, 
and A7034 for date of service October 24, 2022. 
 
You asked the Plan to pay for the supplies identified with codes A7038, A4604, A7032, and A7034. You say 
that you disagree with the Plan's denial. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid physician order for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the supplies identified with codes A7038, A4604, A7032, and 
A7034 for date of service October 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 18, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim must be 
submitted to the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the services until the primary insurer has denied the claim for these services.  Therefore, we decided that the 
Plan does not have to pay for the services provided on January 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided from June 21, 2021, to June 25, 
2021. 
 
You asked the Plan to pay for the medical services. You say that this claim was filed timely. The Plan denied 
your request. The Plan says you did not file your claim in a timely manner. The Plan follows Medicare rules. 
The rules say that claims 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 December 14, 2022. 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 from June 21, 2021, to June 25, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve homemaking services. 
 
You asked the Plan to pre-approve homemaking services. The Plan denied your request. The Plan says this is 
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. Based on this information, we decided that Medicare rules for 
coverage of homemaking services have not been met. The requested services are not reasonable and necessary 
for the diagnosis or treatment of an illness or injury. Therefore, we decided that the Plan does not have to pre-
approve homemaking services.