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

 
We decided that the Plan does not have to pre-approve the reverse power tilt system, extra heavy duty power 
seating upgrade, power tilt drive lockouts, the power tilt/anterior tilt actuator, power seating booster, red 
powder coat, solid backposts, specialized cushions, and other specialized accessories all described by one or 
more units of K0108. 
 
You asked the Plan to pre-approve the specialized wheelchair accessories. You say that the requested features 
should be approved. The Plan denied your request. The Plan says all codes for the extra heavy duty wheelchair 
have been approved. The additional upgrades for the higher weight capacity are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that miscellaneous options and accessories for power 
wheelchairs may be billed with code K0108 when there is no other code to describe the item. It may not be 
used to report standard upgrades for weight or dimension changes of parts of the wheelchair. 
 
In this case, many of the options being described by code K0108 are for additional power and capacity due to a 
beneficiary with a higher weight. The power wheelchair base code has been approved and is for a wheelchair 
with a capacity of 600 pounds or more or for additional power boosts. As noted in the rules, this is considered 
unbundling. In addition, the codes for specialized cushions and back rests/posts are not clearly medical in 
nature and there is no indication that there is no code that adequately describes them. These upgrades appear to 
be for convenience or appearance and are not separately paid and covered by Medicare. Therefore, we decided 
that the Plan does not have to pre-approve the reverse power tilt system, extra heavy duty power seating 
upgrade, power tilt drive lockouts, the power tilt/anterior tilt actuator, power seating booster, red powder coat, 
solid backposts, specialized cushions, and other specialized accessories all described by one or more units of 
K0108.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Myomo Powered Arm Brace (L8702). 
 
You asked the Plan to pre-approve a Myomo Powered Arm Brace. You say that this is medically necessary. 
The Plan denied your request. The Plan says this device 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 Myomo Powered Arm Brace. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found at this time the requested robotic orthosis is not proven to be more beneficial for 
treatment of the patient's medical condition/function of hemiparesis after stroke than any available standard 
therapy. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or 
injury or  to improve the functioning of a malformed body member. 
 
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 Myomo Powered Arm Brace have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Myomo Powered Arm Brace (L8702).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the esophagogastroduodenoscopy (43235). 
 
You asked the Plan to pre-approve the esophagogastroduodenoscopy. You say that you would like 
reconsideration because this service is medically necessary. The Plan denied your request. The Plan says the 
member had gastroesophageal reflux symptoms which went away with appropriate therapy and he does not 
have abnormal signs or symptoms or known disease are present. 
 
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 esophagogastroduodenoscopy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documentation that the member has persistent or recurrent 
symptoms despite optimally-dosed PPI therapy and dietary compliance, dysphagia, vomiting, upper abdominal 
distress, GI bleeding, recent x-ray findings of concern, nor was tissue sampling performed. The member has 
already undergone multiple prior EGD procedures that have yielded no evidence of Barrett's esophagus, nor 
even of esophagitis or any other UGI pathology, to warrant surveillance. LCD criteria, as applies to the 
member, specifically exclude coverage by Medicare of EGD in the member's setting of "uncomplicated 
heartburn responding to medical therapy." 
 
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 esophagogastroduodenoscopy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the esophagogastroduodenoscopy (43235).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom patient lift based on the Likorall 243ES. 
 
You asked the Plan to pre-approve patient lift. You say that this is not a ceiling-mounted lift and is the only lift 
capable of meeting your needs. The Plan denied your request. The Plan says the denial of authorization for this 
equipment is correct, because ceiling-mounted lifts are not covered, and your needs can be met by a bariatric 
floor lift. 
 
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 patient lift. Our reviewer says that you 
do not meet the Medicare criteria for the requested patient lift. Our physician reviewer found the 
documentation does not include an objective medical practitioner (physician, physician assistant, nurse 
practitioner) medical progress note with a physical examination of you, objective weight, and documentation 
that you require or are medically safe to use the requested lift. While you may require a lift, a lift cannot be 
considered safe or necessary without the appropriate treating practitioner progress note and assessment. 
Therefore, the requested lift is not considered medically reasonable and 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 patient lift have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a custom patient lift based on the Likorall 243ES.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with 
suspension sleeve (L1833, L2397) provided to the enrollee on April 3, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The rules say 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. When conducting a review of a 
covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary 
and conducted a face-to-face assessment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the durable medical equipment have not been met. Specifically, medical records do not support a 
prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an 
appropriate use of telehealth. The submitted consultation notes do not support that a physical examination was 
performed. The information submitted does not confirm that Medicare coverage criteria have been met. 
Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee 
orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on April 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
April 9, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient?s medical 
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the 
type and quantity of items ordered and for the frequency of use.  
 
The record shows that documentation submitted did not indicate the provider discussed the need for the billed 
supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to 
pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on April 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee. 
 
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 payment for the laboratory services is included to payment to the facility per Medicare 
guidelines and is ineligible for separate payment to a physician. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 80053: Comprehensive metabolic panel 
 
CPT 80197: Tacrolimus 
 
CPT 82550: Creatine kinase (CK) 
 
CPT 82728: Ferritin 
 
CPT 83540: Assay of iron 
 
CPT 83550: Iron binding capacity 
 
CPT 83880: B-Type Natriuretic Peptide (BNP) 
 
CPT 85007: Blood count 
 
CPT 85027: Blood count 
 
CPT 87497:Infectious agent detection by nucleic acid (DNA or RNA) 
 
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found per the 
Plan?s guidelines. The Plan uses the CMS National Physician Fee Schedule (NFFS) Professional Component 
Technical Component (PC/TC) indicators 3 and 9 to identify laboratory services that are not reimbursable to an 
Independent Laboratory, Reference Laboratory or Non-Reference Laboratory provider in a facility setting.  
PC/TC indicator 3: Technical Component Only Codes, PC/TC indicator 9: PC/TC Concept Not Applicable. 
Therefore, PC for Services billed, would not be reimbursed. 
 
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 laboratory services provided to the enrollee on March 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 27, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the MRI of the brain (70551). You say that you would like reconsideration 
because the services rendered were medically necessary. The Plan denied your request. The Plan says 
utilization of network providers is required when possible and available. 
 
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 has network providers 
available who can provide 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 medical services provided on January 27, 2020 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on January 16, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in network. 
 
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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on January 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for consultation on X-ray examination made elsewhere and 
written report. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says this service is not covered under Medicare or the Health Plan. 
 
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 service have not been met. Per 2019 National Physician Fee 
Schedule Relative Value File October Release, procedure code 76140 has status code of ?I? which is not valid 
for Medicare purposes. Therefore, we decided that the Plan does not have to pay for consultation on X-ray 
examination made elsewhere and written report.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
March 27, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the billed date of service was after the submitted invoice, therefore the billed code 
cannot be verified. 
 
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 not contain a valid proof of delivery to support medical necessity for the supplies provided in 
this case. The date on the delivery is March 20, 2020 but the date of service is March 27, 2020. Therefore the 
billed code cannot be verified. 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 a lumbar-sacral 
orthosis (L0650) provided to the enrollee on March 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent 
deep vein thrombosis. The Plan denied your request. The Plan says PCDs billed by E0675 are not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0675).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on September 30, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. The documentation provided does not contain medical records for the 
date of service in question. Without records, it cannot be determined that Medicare coverage criteria have been 
met. Therefore, we decided that the Plan does not have to pay for the services provided on September 30, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the continued 
SNF stay was 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 above 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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99190) provided on February 10, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for these 
services is included in the Part A DRG payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. Payment for all fees related to this service would have been included under the facility claim. 
Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on February 
10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 6, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for laboratory test. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-
network with the Plan and the referring provider is also out-of-network with the Plan. 
 
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 has network providers 
available who can provide 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 medical services provided on March 6, 2020 
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 domiciliary or rest home visit (99336) rendered by the 
out of network (OON) provider on March 26, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the domiciliary or rest home visit (99336) rendered by the out of network (OON) provider on 
March 26, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services coded 90832 provided. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 code 90832 is not supported in the medical record. Specifically, this code was billed with 
place of service, 31 (skilled nursing facility). There is a more appropriate outpatient code of place of service 
that should be billed with this claim. Based on this information, we decided that Medicare rules for coverage of 
the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the 
psychotherapy services coded 90832 provided.