Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 skilled nursing visits and 13 home health aide visits. 
 
You asked the Plan to pre-approve 6 skilled nursing visits and 13 home health aide visits. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 6 skilled nursing visits and 13 home 
health aide visits. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found you do not meet criteria for continued services as there are no recent medical records by your physician 
indicating medical reasoning behind the necessity. At this present time your condition was noted to be stable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 6 skilled nursing visits and 13 home health aide visits have not been met. 
Therefore, we decided that the Plan does not have to pre-approve 6 skilled nursing visits and 13 home health 
aide visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the abdomen. 
 
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the clinical information shows that the enrollee had the 
same test or one similar, but do not explain why those results were not sufficient for evaluation and treatment 
of the current clinical condition. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the 
medical necessity criteria for a repeat MRI of the abdomen at this time are not met. Our physician reviewer 
found the initial MRI did not show evidence for a discrete mass lesion nor for malignancy on the bile duct 
sampling. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an MRI of the abdomen.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (A0260). 
 
You asked the Plan to pre-approve the semi-electric hospital bed. You say that you would like reconsideration 
because the frame for your approved mattress is broken making one side of the mattress unstable. The Plan 
denied your request. The Plan says criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
2. Requires attachments which can only be attached to a hospital bed; AND 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the records do not show that you have a medical condition which requires frequent 
positioning of the body in ways not feasible with an ordinary bed like congestive heart failure, chronic 
pulmonary disease, or problems with aspiration. Our physician reviewer found elevation of the head/upper 
body less than 30 degrees does not usually require the use of a hospital bed, or require positioning of the body 
in ways not feasible with an ordinary bed in order to alleviate pain. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (A0260).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for CT of the head (70470) provided on May 19, 2020. 
 
You asked the Plan to pay for the CT of the head. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that CPT code 70470 is a column II procedure 
to the column I procedure, 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 70470 is supported in the record. Specifically, column II code 70470 has not been billed 
by a provider with the same NPI as column I code 70496. It is not appropriate to apply NCCI edits to services 
billed by providers with separate NPIs. Based on this information, we decided that Medicare rules for coverage 
of the CT of the head have been met. Therefore, we decided that the Plan has to pay for CT of the head (70470) 
provided on May 19, 2020.  
 
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: Transportation
Decision: Favorable

We decided that the Plan has to pay for ALS emergency ambulance (A0427) and ground mileage (A0425) 
provided on October 7, 2019. 
 
You asked the Plan to pay for the ambulance services. You say that sending an appeal with medical records. 
Kindly review the records to process the claim. The Plan denied your request. The Plan says that the records 
does not support medical necessity for ambulance transport. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patient's health. The Plan follows the same rules.  
 
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 ambulance services. Our reviewer says 
that the requested items/services is considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee admitted to heroin use and had stable vital signs at presentation but was administered 
Narcan. Unfortunately, in the setting of possible overdose or illicit drug use, there is indication for ambulance 
transport as patient is by definition impaired. In addition, the level of additional impairment is hard to ascertain. 
Ambulance transport indicated and denial overturned. 
 
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 ambulance services have been met. Therefore, we decided that the Plan has 
to pay for ALS emergency ambulance (A0427) and ground mileage (A0425) provided on October 7, 2019.  
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Otezla for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this medication is medically necessary. The Plan 
denied your request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Otezla for the enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on June 15, 2020 
and billed under code 99214. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim was denied because another provider in the same group with the same 
specialty previously billed this service for the dame date and the same enrollee. Medicare billing criteria are not 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim submitted cannot be paid due 
to a previous submission for the same enrollee by another provider in the same group. Based on this 
information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we 
decided that the Plan does not have to pay for physician services provided to the enrollee on June 15, 2020, billed 
under code 99214.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve coronary artery catheterization (93458). 
 
You asked the Plan to pre-approve coronary artery catheterization. You say that the services are necessary. The 
Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
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 coronary artery catheterization. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found based on these criteria, use of coronary angiography is uncertain but receives a 
higher (6/9) rating of appropriate use--making it medically reasonable for this indication based on shared 
decision making with the enrollee. The enrollee therefore meets CMS criteria noted for medical necessity as 
coronary angiography is "furnished in accordance with accepted medical practice for the diagnosis and 
treatment of the patient's condition" as this meets published clinical guidelines for appropriate use. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of coronary artery catheterization have been met. Therefore, we decided that the 
Plan has to pre-approve coronary artery catheterization (93458).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the lab services you received on September 20, 2019. 
 
You asked the Plan to pay for the lab services. You say that this should be covered. The Plan denied your 
request. The Plan says that this is not a covered service. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the lab services by a contract provider. The file does not show that the Plan provided notice 
that the lab services would not be covered. Under Medicare rules, this means the lab services is considered 
approved by the Plan. You had a reasonable expectation that the lab services would be covered under your 
plan. Therefore, we decided that the Plan has to pay for the lab services you received on September 20, 2019.  
 
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 waive the copayments for wound debridement provided from 
November 7, 2019, to December 11, 2019. 
 
You asked the Plan to waive the copayments for wound debridement. You say that you disagree with the 
charges because you feel the enrollee should only owe a specialist copayment. The Plan denied your request. 
The Plan says the claims were processed correctly and the enrollee is being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $350 copayment for outpatient surgery and other medical services provided at hospital outpatient 
facilities and ambulatory surgical centers.  
 
The enrollee received wound debridement from November 7, 2019, to December 11, 2019, for a total of 5 
visits. Wound debridement is considered an outpatient surgical procedure. Therefore, the enrollee is 
responsible to pay the total allowed amount of $694.60, which is less than the total copayment amount.  
 
The enrollee has been asked to pay the total allowed amount of $694.60 for wound debridement. Wound 
debridement falls within the outpatient surgery and other medical services provided at hospital outpatient 
facilities and ambulatory surgical centers benefit category. This means that the enrollee has been asked to pay 
the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayments for wound debridement provided from November 7, 2019, to December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for IV tubing (S1015) and infection supplies (S8301) provided 
on June 15, 2020. 
 
You asked the Plan to pay for the supplies. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says CPT codes S1015 and S8301 have a status indicator of 
I which is not valid 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 CPT code. 
 
We find that CPT code S1015 and S8301 is not supported in the record. Specifically, per the Physician Fee 
Schedule, CPT codes S1015 and S8301 have a status indicator of I. This means that these CPT codes are not 
valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the 
supplies have not been met. Therefore, we decided that the Plan does not have to pay for IV tubing (S1015) and 
infection supplies (S8301) provided on June 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services coded A0429 provided on June 14, 
2020. 
 
You asked the Plan to pay for the ambulance 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 A0429 is not supported in the medical record. Specifically, this code was billed with 
QL Modifier. The documentation supports that the enrollee was pronounced dead after the ambulance was 
called. Based on this information, we decided that Medicare rules for coverage of the ambulance services have 
not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services coded 
A0429 provided on June 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive dental services (D1999) provided 
on May 19, 2020. 
 
You asked the Plan to pay for the dental service. You say that the new personal protective equipment (PPE) 
requirements increase the overhead for your dental practice. The Plan denied your request. The Plan says 
unspecified preventive dental service is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
unspecified preventive dental services (D1999) provided on May 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator, electronic shock unit provided 
to the enrollee on June 16, 2020. 
 
You asked the Plan to pay for these services. You say that this was medically necessary. The Plan denied your 
request. The Plan says that the enrollee does not meet criteria for coverage. 
 
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 relevant medical records which support medical necessity 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 neuromuscular stimulator, 
electronic shock unit provided to the enrollee on June 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the extended warranty provided to the enrollee on April 16, 
202. 
 
You asked the Plan to pay for the extended warranty. You say that the power lift chair was medically necessary 
for the enrollee. The Plan denied your request. The Plan says that the warranty is not covered. 
 
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. Therefore, we 
decided that the Plan does not have to pay for the extended warranty provided to the enrollee on April 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) 
provided to the enrollee on June 11, 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 knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on 
June 11, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care. 
 
You asked the Plan to pre-approve home health care. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health care. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there are no medical records that 
indicate medical necessity for skilled nursing services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device. 
 
You asked the Plan to pay for an intermittent limb compression device. You say that the device should be 
covered. The Plan denied your request. The Plan says the documentation failed to prove that sufficient 
evidence of four-week trial of conservative therapy. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0651 is covered for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. A four-week 
trial of conservative therapy demonstrating failed response to treatment is required. 
 
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, the record does not show that the enrollee had at least 
four weeks of regular home usage of conservative therapy including compression garments, exercise and 
elevation. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression 
device.