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

 
We decided that the Plan does not have to pre-approve a Group 1 power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you cannot use a walker. The Plan denied your 
request. The Plan says the services are 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 these services. Our reviewer says that 
you do not meet the criteria for coverage. Our physician reviewer found the records show that you have a 
personal mobility deficit but it does not impair your ability to complete mobility-related activities of daily 
living (MRADLs) in the home. The documentation does not show that your mobility deficit is unable to be 
helped by a manual wheelchair. It is not clear that you can safely maneuver the PWC in the home or that the 
PWC will significantly improve your completion of MRADLs in the home. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a Group 1 power wheelchair (PWC).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve hepatobiliary system imaging, including gallbladder when present; 
with pharmacologic intervention, including quantitative measurement(s) when performed (CPT Code 78227). 
 
You asked the Plan to pre-approve the service. You say that due to the persistent nature of the member's 
symptoms with alarm symptoms, such as weight loss, you would like to move forward with further 
investigation with a nuclear HIDA scan to try to identify the cause of the member's persistent discomfort so 
you can improve their condition and health. The Plan denied your request. The Plan says that the service is not 
necessary. 
 
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 the service. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the patient has had extensive workup for abdominal pain and has biliary sludge on imaging 
study. Our physician reviewer feels the HIDA scan is reasonable given the negative workup thus far and 
finding of biliary sludge.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have been met. Therefore, we decided that the Plan has to pre-
approve hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention, 
including quantitative measurement(s) when performed (CPT Code 78227).  
 
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 pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no formal documentation of cognitive changes. 
 
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 monitor. Our reviewer says that the 
requested monitor is not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the medical records provided there is no documentation that you are using insulin at least three 
times per day as prescribed. Records indicate that you do not take your Humalog as recommended. You have 
not been compliant with frequent testing. The records indicate that you mostly check your glucose in the 
mornings. 
 
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an oxygen concentrator provided on July 
11, 2020. 
 
You asked the Plan to waive the coinsurance for an oxygen concentrator. You say that you disagree with the 
charges because you were told that you would not owe anything for the device. The Plan denied your request. 
The Plan says the claims were processed correctly and you are 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). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment and related supplies.  
 
You received an oxygen concentrator on July 11, 2020. The allowed amount is $135 and 20% of that is $27.  
 
You have been asked to pay the total coinsurance amount of $27 for an oxygen concentrator. An oxygen 
concentrator falls within the durable medical equipment and related supplies 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 coinsurance for an oxygen concentrator provided on July 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PureWick external catheters. 
 
You asked the Plan to pre-approve incontinence supplies. You say that this item meets all of the requirements 
for durable medical equipment. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve PureWick external catheters.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional chiropractic services provided from May 4, 
2020, to June 18, 2020. 
 
You asked the Plan to pay for the additional chiropractic services. You say that you were told by the provider 
there would only be a $20 copayment. The Plan denied your request. The Plan says only manual manipulation 
of the spine to correct subluxation is covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the additional chiropractic services provided from May 4, 2020, to June 
18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F5 and MTHFR gene testing (81241, 81291). 
 
You asked the Plan to pre-approve F5 and MTHFR gene testing. You say that you need this to diagnose your 
symptoms. The Plan denied your request. The Plan says this is not indicated for your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that F5 genetic testing is indicated for pregnant 
women with risk factors listed above. There is no clinical indication for MTHFR genotyping in any population. 
 
We looked at the file and Medicare rules. The record does not show that you are pregnant. The requested tests 
are not indicated for you at this time. Based on this information, we decided that Medicare rules for coverage of 
F5 and MTHFR gene testing have not been met. Therefore, we decided that the Plan does not have to pre-
approve F5 and MTHFR gene testing (81241, 81291).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for Positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) coded 78816 provided on June 22, 2020. 
 
You asked the Plan to pay for the PET with CT. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says that the services were not billed with an appropriate diagnosis 
code. 
 
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 78816 is Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for 
attenuation correction and anatomical localization imaging; whole body. 
 
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 PET with CT. Our reviewer says that the 
documentation supports the services billed. Our coding reviewer found that the documentation submitted meets 
criteria for the diagnosis code submitted (C83.30 Diffuse large B-cell lymphoma, unspecified site). Diagnosis 
code C83.30 is a cancer diagnosis in an unspecified site. Diffuse large B-cell lymphoma, or DLBCL, is a 
cancer that starts in white blood cells called lymphocytes. It usually grows in lymph nodes--pea sized glands in 
the neck, groin, armpits, and elsewhere that are of your immune system. It can also show up in other parts of 
the body. Therefore, the billing of code 78816 with diagnosis code C83.30 should be covered. 
 
We looked at this coder?s review, the file, and Medicare rules. The rules state that effective for claims with 
dates of service on or after April 3, 2009, contractors shall accept FDG PET claims with modifier ?PS for the 
subsequent treatment strategy for solid tumors using a CPT code above AND a cancer diagnosis code. The 
documentation supports that this PET scan was billed with a cancer diagnosis code. Based on this information, 
we decided that Medicare rules for coverage of the PET with CT have been met. Therefore, we decided that the 
Plan has to pay for Positron emission tomography (PET) with concurrently acquired computed tomography 
(CT) coded 78816 provided on June 22, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
November 25, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that medically necessary services were rendered in 
good faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network provider. 
 
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 subsequent nursing facility care (99308) 
provided on November 25, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation services provided on June 12, 
2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the enrollee 
could have been safely transported by another type of vehicle. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. 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 services provided. Our physician 
reviewer found that the enrollee was transported via ambulance due to her feeling dizzy and weak with 
vomiting. She was given a vomit bag, placed on the stretcher and transported to the emergency department. Her 
vitals were stable. Her strength was normal, and she was alert and oriented. The provided documentation does 
not support that other means of transport were contraindicated. The documentation does not support that the 
enrollee needed the expertise and equipment available in an ambulance for safe transport. The documentation 
does not support that ambulance transportation was reasonable or medically necessary in this case. 
 
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 provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance transportation services provided on June 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergent transportation. 
 
You asked the Plan to pre-approve non-emergent transportation. You say that you depend on the transportation 
services offered by the Plan since you cannot attend your medical appointments. The Plan denied your request. 
The Plan says you used your maximum benefit for non-emergency transportation. The Plan states to consider 
approval by expectation the patient has physical limitations that require personnel to move patient in a 
stretcher, or other medical condition that prevents the patient from using regular transportation such as private 
vehicles, public transportation, family and municipal transportation. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
 
 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve non-emergent transportation.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide visits for fourteen (14) hours a week 
(CPT Code G0156 X448). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 the services. Our physician reviewer 
found based on the medical records provided there is no documentation that the additional seven hours of home 
health aide services per week meet the definition of home health aide services as per Sections A, B, C, D & E 
of Section 50.2. Records indicate the enrollee is disorganized and forgetful with impaired decision making and 
requires slight assistance or supervision with some activities of daily living but otherwise no acute skilled 
needs are documented necessitating the seven additional hours of home health aide services per week. There is 
no documentation that the additional seven hours of home health aide services per week are reasonable and 
necessary for the treatment of the patient?s illness or injury by the skilled professional staff. Records indicate 
the enrollee is disorganized and forgetful with impaired decision making and requires slight assistance or 
supervision with some activities of daily living but otherwise no acute skilled needs are documented 
necessitating the seven additional hours of home health aide services per week. 
 
 
 
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 home health aide visits for fourteen (14) hours a week (CPT Code G0156 X448).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (15736, 25101, 25280, 25608) provided 
June 2, 2020. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the services billed. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 
15736. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means 
that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. CPT 
codes 25101, 25280, and 25608 were billed with a modifier indicating a surgical assistant also, however the 
documentation did not support the role of the surgical assistant during the procedure. Based upon this 
information, we find that Medicare coverage criteria for the surgical services have not been met. Therefore, we 
decided that the Plan does not have to pay for surgical services (15736, 25101, 25280, 25608) provided June 2, 
2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you do not 
have complex wound care needs, or require daily therapies. 
 
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. 
 
Continued SNF care beyond November 20, 2020, was requested. 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 continued services. Our physician reviewer found that from a nursing perspective, you 
received oral medications, and had stable vital signs. There are no identifiable skilled nursing service needs. 
Regarding rehab services, you were at a modified independent to contact guard assist level with functional 
mobility. You required varying assist with activities of daily living. There are no identifiable skilled therapy 
service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity 
of illness or intensity of service criteria for 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 continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you need this chair due to fall risks. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (64636, 64635). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that this is medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that dual medial branch blocks (MBBs) (a series of 
two MBBs) are necessary to diagnose facet pain due to the unacceptably high false positive rate of single MBB 
injections. 
 
We looked at the file and Medicare rules. The record shows documentation of only one set of MBBs being 
performed. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation 
have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation 
(64636, 64635).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on May 
1, 2020. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not have to 
pay the $90 copayment. 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for the emergency room visit. the emergency room visit falls 
within the emergency care 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 
emergency room visit provided on May 1, 2020.