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

We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the heart (75557). 
 
You asked the Plan to pre-approve an MRI of the heart. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
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 an MRI of the heart. Our reviewer says 
that the services are medically necessary. Our physician reviewer found certainly you must have pulmonary 
venous evaluation prior to your planned ablation procedure. The operating cardiologist has the option to choose 
whether MRI or Cardiac computed tomography (CT) is his/her method of choice for such evaluation based 
upon the experience at the hospital at which the procedure will be performed. Each examination has its 
advantages and disadvantages and whichever the operating physician finds the more reliable should be 
approved. 
 
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 MRI of the heart have been met. Therefore, we decided that the Plan has to 
pre-approve a magnetic resonance imaging (MRI) of the heart (75557).  
 
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: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on June 13, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 13, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement wheelchair. 
 
You asked the Plan to pre-approve a standard hemi wheelchair with elevating leg rests. You say that your 
wheelchair is damaged so you need a new one. The Plan denied your request. The Plan says they requested 
evidence of irreparable damage but there was none submitted. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a lightweight wheelchair. The lightweight wheelchair serves the same purpose as 
a replacement standard hemi wheelchair with elevating leg rests. Your wheelchair is still within the 5-year 
RUL and the documentation submitted does not show that the wheelchair is irreparably worn, irreparably 
damaged, or that you had a change in medical condition to warrant the hemi wheelchair at issue.  
 
 
 
Based on the records provided, there is no indication the wheelchair requested meets Medicare coverage 
criteria for replacement. Medicare coverage criteria for wheelchair replacement is not met. Therefore, we 
decided that the Plan does not have to pre-approve a replacement wheelchair.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the chest (71250). 
 
You asked the Plan to pre-approve a CT scan of the chest. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan of the chest. Our reviewer 
says that the services are medically necessary. Our physician reviewer found the greater than 20% weight loss 
with a body mass index (BMI) of 19 is worrisome for occult malignancy. Also, you have a history of aortic 
stenosis which can be associated with ascending aortic aneurysm. While a chest x-ray result is not in the 
records the fact of the matter is that even a normal chest x-ray report would not obviate the need for a CT of the 
chest. Based on the clinical information in this case the request for CT of the chest is 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 CT scan of the chest have been met. Therefore, we decided that the Plan has 
to pre-approve a computed tomography (CT) scan of the chest (71250).  
 
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 copayment for the office visit (99214) and 
electrocardiogram (93010) provided on August 25, 2020. 
 
You asked the Plan to waive the copayment for the office visit and electrocardiogram. You say that you would 
like reconsideration because you should only have one copayment per visit. The Plan denied your request. The 
Plan says your benefits were applied correctly as you have a $25 copayment for the specialist visit and a $25 
copayment for the diagnostic service. 
 
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 $25 
copayment for the specialist office visit and a $25 copayment for non-radiologic diagnostic services. 
 
You have been asked to pay $25 for the office visit and $8.43 for the electrocardiogram. This means that you 
have been asked to pay the less than your contracted amount 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 office visit (99214) and electrocardiogram (93010) provided on August 25, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says there is 
no active management of comorbid conditions, and no complex treatment required at this level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our physician 
reviewer found that the enrollee presented to the emergency room with respiratory distress. Found to have 
elevated WBC and hyperkalemia, given fluid bolus and broad spectrum antibiotics and admitted to ICU. The 
enrollee still requires acute care hospital services and is receiving appropriate care at the present acute care 
facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital 
where he is currently receiving care. There are no services available at the LTACH that the enrollee requires 
that are not available at the health care setting being offered by the health plan. The requested LTACH services 
are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and 
able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulpal debridement (D3221) provided on August 19, 
2020. 
 
You asked the Plan to pay for the pulpal debridement. You say that this emergency repair was needed to take 
care of your tooth infection. The Plan denied your request. The Plan says this service is not a covered benefit 
under your dental plan. 
 
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 pulpal 
debridement (D3221) provided on August 19, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for methylprednisolone acetate injection (HCPCS J1040) services provided 
to the enrollee on March 16, 2020. 
 
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 that Healthcare Common Procedure Coding System (HCPCS) code J1040 (1 Unit) remains not 
supported. 
 
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 
HCPCS code J1040 is "injection, methylprednisolone acetate, 80 mg." 
 
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 services. Our reviewer says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found per the 
reviewed documentation, the enrollee underwent a methylprednisolone acetate injection (HCPCS J1040) on 
March 16, 2020. The injection was documented in the office note. It was given under sterile conditions with 
Lidocaine and Marcaine. The review of the provided documentation demonstrates that the records indicate that 
J1040 was administered on March 16, 2020. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
methylprednisolone acetate injection (HCPCS J1040) services provided to the enrollee on March 16, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the basic metabolic panel coded 80048 provided on October 
1, 2019. 
 
You asked the Plan to pay for the basic metabolic panel. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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 80048 is basic metabolic panel (Calcium, total) This 
panel must include the following: Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride 
(82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) 
(84520). 
 
We find that CPT code 80048 is not supported in the medical record. Specifically, the documentation submitted 
did not include documentation for the billed date of service. Based on this information, we decided that 
Medicare rules for coverage of the basic metabolic panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the basic metabolic panel coded 80048 provided on October 1, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87541, 87581, 87631, 
87635, 87640, 87798) provided May 1, 2020. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says Original Medicare is liable for payment for these services. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87541, 87581, 87631, 
87635, 87640, 87798) provided May 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve paravertebral facet joint injections. 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary for the spurs in your 
neck. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injections. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the pain is associated with radiculopathy, and there is no documentation provided indicating 
that the facet joint is the main source of pain. The review has determined that the requested paravertebral facet 
joint injections are not medically necessary or reasonable. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve paravertebral facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), of diagnostic or therapeutic substance(s) 
(eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including 
needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging 
guidance (ie, fluoroscopy or CT) (CPT Code 62321). 
 
You asked the Plan to pre-approve the services. You say that the injection minimizes your pain and allows you 
that have a better quality of life. The Plan denied your request. The Plan says these criteria are not met because 
your doctor must send the Plan notes that say for at least six weeks in the last six months, you did neck 
exercises or stretches (formal physical therapy, chiropractic treatments, or supervised home exercise program). 
The Plan states your doctor can give a medical reason you can't exercise. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found evidence based medical literature offers some support for the use of cervical epidural steroid 
injections for the treatment of cervical radiculopathy when conservative treatment has failed, but generally not 
above the C6/7 level. In this case, there is no clear evidence of cervical radiculopathy. There is no 
documentation of cervical radicular symptoms. There is no documentation of any focal neurologic deficit. 
There are no cervical spine imaging findings documented by the requesting physician, and an imaging report is  
not provided for review. This request lacks specificity relative to the level of planned injection. Therefore, this 
request for cervicothoracic interlaminar epidural steroid injection is 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, 
opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, 
interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) 
(CPT Code 62321).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of 
abdomen and pelvis provided on April 30, 2019. 
 
You asked the Plan to waive the copayment for the CT scan of abdomen and pelvis. You say that you are 
confused by your copayment amount. The Plan denied your request. The Plan says the copayment applied 
correctly in this case. 
 
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 $200 
copayment for Medicare-covered diagnostic radiology services.  
 
You have been asked to pay a $200 copayment for the CT scan of abdomen and pelvis. The service provided 
falls within the Medicare-covered diagnostic radiology services benefit category. 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 computed tomography (CT) scan of abdomen and pelvis provided on April 30, 
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed for the enrollee. 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no clinical evidence of a need for frequent and immediate need for a change in 
body position. 
 
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 bed. Our reviewer says that the 
requested bed is not medically reasonable or necessary. Our physician reviewer found the documentation does 
not clearly reveal that the enrollee's condition has failed positioning of the bed in ways not feasible in an 
ordinary bed, or why positioning of the bed in other ways is not feasible. The documentation does not support a 
 
 
need for an immediate change in body position or special attachments that cannot be fixed on an ordinary bed. 
The head of the bed does not need to be elevated more than 30 degrees most of the time due to congestive heart 
failure, chronic pulmonary disease, or problems with aspiration. The request for a semi-electric hospital bed is 
not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the bed have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a semi-electric hospital bed for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on July 13, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 lab work provided on July 13, 2020 by an out of 
network (OON) provider.