Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the trauma response team services provided on December 20, 
2019 billed with code G0390. 
 
You asked the Plan to pay for the services described by G0390. You say that this claim should be paid as 
billed. The Plan denied your request. The Plan says this code was billed without a related critical care service. 
 
The Plan must follow Medicare rules. Medicare rules say that payment can be made for trauma response 
activation required for critical care services and, when provided, code 99291 and code G0390 are billed.  
 
In this case, G0390 should only be billed when 99291 is also reported. Therefore, we decided that the Plan does 
not have to pay for the trauma response team services provided on December 20, 2019 billed with code G0390.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair repairs. 
 
You asked the Plan to pre-approve power wheelchair repairs. You say that you need this chair and do not know 
why it does not meet criteria. The Plan denied your request. The Plan says the denial of authorization is correct, 
because you do not meet the criteria for a power wheelchair and a custom manual wheelchair was provided to 
you. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair repairs. Our reviewer 
says that you do not meet the Medicare criteria for the requested power wheelchair repairs. Our physician 
reviewer found the documentation does reveal that you have a personal mobility deficit, but it is not clear that 
you are unable to perform mobility-related activities of daily living (MRADL) in the home with your current 
wheelchair. The documentation does not reveal why your mobility deficit is unable to be helped by a manual 
wheelchair. The documentation is not clear that you can safely maneuver the power wheelchair in the home. 
Therefore, the requested power wheelchair repairs are not 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 power wheelchair repairs have not been met. Therefore, we decided that the 
Plan does not have to pre-approve power wheelchair repairs.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for chiropractic services provided on January 
17, 2020. 
 
You asked the Plan to waive the deductible for chiropractic services. The Plan denied your request. The Plan 
says the deductible applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that your combined in-network and out-of-network medical deductible is $198. This 
is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. 
Until you have paid the deductible amount, you must pay the full cost for most of your covered services. 
 
 
 
  
 
 
The item or service you asked the Plan to waive the deductible for falls within the "Chiropractic Services" 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $198 
deductible applies to chiropractic services. This cost sharing is a contractual obligation that had not been met at 
the time chiropractic services were received on January 17, 2020. Therefore, we decided that the Plan does not 
have to waive the deductible for chiropractic services provided on January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation services rendered on July 13, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the 
same specialty must bill and be paid as though they were a single physician.  
 
We looked at the file and Medicare rules. The file shows that procedure code 99222 (initial hospital care) was 
billed by the same provider group for the same date of service. 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 pay for the evaluation services rendered on July 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Praluent pen. 
 
You asked the Plan to pre-approve Praluent pen. You say that this treatment is medically necessary. The Plan 
denied your request. The Plan says rules for pre-approval have not been met. 
 
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 Praluent pen.  
 
Benefits for Praluent pen 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses you purchased August 15, 2020. 
 
You asked the Plan to pay for the eyeglasses. You say that you would like the Plan to pay for the eyeglasses 
you purchased. The Plan denied your request. The Plan says you exceeded the allowed services. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services once every 24 months. 
 
We looked at the file and the Plan's rules. The file indicates that the Plan covered eyeglasses in January 2020 
and you exhausted your Plan benefit at this time. Based on this information, we decided that the Plan's rules for 
coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the 
eyeglasses you purchased August 15, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit billed with 99284 on November 4, 
2019. 
 
You asked the Plan to pay for an emergency room visit. You say that this was billed correctly. 
 The Plan denied your request. The Plan says 99283 is appropriate for the service provided. 
 
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 99284 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: A detailed history; A detailed 
examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care 
with other physicians, other qualified health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not 
pose an immediate significant threat to life or physiologic function. 
 
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 an emergency room visit. Our reviewer says 
that this code is not supported. Our physician reviewer found the medical records document medical decision 
making of low complexity. There is a more appropriate code to report. 
 
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 emergency room visit have not been met. Therefore, we decided that the 
Plan does not have to pay for an emergency room visit billed with 99284 on November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the repeat, full Transthoracic Echocardiography. 
 
You asked the Plan to pre-approve the Transthoracic Echocardiography. You say that you would like 
reconsideration because this service is medically necessary. The Plan denied your request. The Plan says the 
member does not meet Medicare coverage criteria for this service. 
 
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 Transthoracic Echocardiography. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the member is clinically stable and with normalized PA pressure by 
echo estimate about 6 months ago while on sildenafil therapy.  A focused follow up echocardiogram to reassess 
pulmonary artery pressure and right ventricle size/function is most appropriate in this circumstance as opposed 
to a complete echocardiogram. 
 
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 Transthoracic Echocardiography have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the repeat, full Transthoracic Echocardiography.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 29, 2020 by an out of 
network provider. 
 
You asked the Plan to pay for the office visit. You say that you do not know why the claim was denied. The 
Plan denied your request. The Plan says you did not request 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 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 office visit provided on June 29, 2020 by an 
out of network provider.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for emergency room services (99285, 93005) provided on June 27, 2020. 
 
You asked the Plan to pay for emergency room services. You say that this should be covered. The Plan denied 
your request. The Plan says that this was not billed with a necessary modifier. 
 
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 states that these services require modifier 25; however, the case file 
does not include medical records or information on what other procedures took place on this date of service 
that would necessitate this modifier, and no further information on what Medicare rules were used to deny 
these services has been provided. The case file also states a corrected claim had been received, preventing the 
original claim from being reprocessed, but the Plan has confirmed a corrected claim has not been received. 
Therefore, we decided that the Plan has to pay for emergency room services (99285, 93005) provided on June 
27, 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: 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 July 13, 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 
enrollees 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 July 13, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient care provided from May 2, 2020, to May 10, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the enrollee was 
readmitted for the same condition. 
 
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 has not provided records, claim form, or EOB for the previous 
admission. Without these records, it cannot be determined that the admission at issue was for the same 
condition/symptoms. Without supporting documentation, the Plan?s denial cannot be substantiated. Therefore, 
we decided that the Plan has to pay for the inpatient care provided from May 2, 2020, to May 10, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 12 and 14. 
 
You asked the Plan to pre-approve the core build up. You say that the enrollee needs treatment for their dental 
problems. You say that he is unable to chew food thoroughly before swallowing. You also say that the enrollee 
has weakness in their esophagus making it important that they be able to chew properly. The Plan denied your 
request. The Plan says core build up is not listed as a covered service. The Plan also says that if a service is not 
listed then it is not covered. 
 
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 pre-approve core 
build up (D2950) for teeth # 12 and 14.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten physical therapy visits. 
 
You asked the Plan to pre-approve ten physical therapy visits. You say that the additional physical therapy is 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested physical 
therapy is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 ten physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the patient has had extensive therapy for this 
condition, and it does not appear that the patient requires the unique skills of a professional therapist to safely 
and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, 
or under the supervision of a therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
 
 
Medicare rules for coverage of ten physical therapy visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve ten physical therapy visits.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided on May 11, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you had an urgent care visit the next 
day to place a cast. You say that the ER copayment should be waived under your plan. The Plan denied your 
request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for each emergency room visit.  
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" 
benefit category. The records show that you were treated in a specialist's office the day after the ER visit. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the ER visit provided on May 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6542. 
 
You asked the Plan to pre-approve the compression stockings. You say that you were authorized to be filled by 
comfort care, but they do not carry the product. The Plan denied your request. The Plan says gradient 
compression stockings A6542 are non-covered when there is no qualifying wound. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6542 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
 
 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6542.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA genetic testing. 
 
You asked the Plan to pre-approve BRCA genetic testing. You say that the requested BRCA genetic testing is 
medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for BRCA 
genetic testing. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say there are certain criteria that must be met for the coverage of BRCA 
genetic testing. 
 
We looked at the file and Medicare rules. Medicare says BRCA genetic testing is not reasonable and necessary 
for individuals with no personal history of breast, ovarian, fallopian tube, primary peritoneal, pancreatic, or 
prostate cancer. Such testing is considered screening and is excluded by Medicare statue. The file shows that 
you are requesting this test for screening purposes only due to a family history of cancer with no personal 
history of cancer. Based on this information, we decided that Medicare rules for coverage of BRCA genetic 
testing have not been met. Therefore, we decided that the Plan does not have to pre-approve BRCA genetic 
testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on May 12, 2020 billed at 
131 minutes. 
 
You asked the Plan to pay for the amount of anesthesia time billed. You say that the medical records support 
the billed services. The Plan denied your request. The Plan says the total time reported on the claim does not 
match what is documented in the record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual time in minutes 
spent providing anesthesia care. This time starts when the anesthetist begins to prepare the patient and ends 
when the patient is placed safely under postoperative care. 
 
The documentation supports only 119 minutes of anesthesia time. The record shows that anesthesia was in 
room at 0836 and anesthesia handoff was documented at 1035. The 131 minutes billed would indicate patient 
handoff was at 1047. There is no notation of this time anywhere in the record. As such, we find that the claim is 
not supported as billed. 
 Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on May 12, 2020 
billed at 131 minutes.