Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided from February 28, 2020, to March 4, 2020.You asked the Plan to pay forthe home health services. The Plan denied your request. The Plan says the services were billed incorrectly.The Plan must follow Medicare rules. Medicare rules say that effective for periods of care beginning on and after January 1, 2020, the original HH PPS system is replaced with the Patient-Driven Grouping Model. We looked at the file and Medicare rules. Per Medicare rules and the HIPPS code master list, code 1AFK2 isno longer listed as a valid code after January 1, 2020. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met.Therefore, we decided that the Plan does not have to pay forthe home health services provided from February 28, 2020, to March 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine disposable supplies (A0398) provided on  
June 23, 2020. 
 
You asked the Plan to pay for the routine disposable supplies. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says that routine disposable supplies 
are not separately payable. 
 
The rules say that effective January 1, 2006, items and services which include but are not limited to oxygen, 
drugs, extra attendants, supplies, EKG, and night differential are no longer paid separately for ambulance 
services. The Plan follows the same rules.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the routine disposable supplies have not been met. Specifically, these supplies are not separately 
payable from the ambulance transport. Therefore, we decided that the Plan does not have to pay for the routine 
disposable supplies (A0398) provided on June 23,2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that you want to try to get 
back to a position where you can do things for yourself. You say that if you stop therapy you will end up in a 
wheelchair. The Plan denied your request. The Plan says additional visits are 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 10 additional 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 says that the unique skills of a professional 
therapist are not required to safely and effectively provide ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device (L8702). 
 
You asked the Plan to pre-approve the motion assist device. You say that you would like reconsideration 
because this device is medically necessary. The Plan denied your request. The Plan says this device is 
experimental and investigational. 
 
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 motion assist device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested device is not the standard of care for the member's condition over 
standard treatment including treatment such as physical and occupational therapy, strengthening exercises, 
constraint induced movement therapy or Botox injections for spasticity. 
 
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 motion assist device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a powered upper extremity range of motion assist device (L8702).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional routine transportation services (A0120).You asked the Plan to pre-approvethese services. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says theenrolleehas exhausted the allowable routine trips for this calendar year.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 40 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decidedthat the enrolleehasexhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approveadditional routine transportation services (A0120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee is currently receiving home 
health therapy. The note dated September 11, 2020, states she needs minimal assist to roll, sit up, and lie down. 
She needs stand by assist to walk 45 feet with a four wheeled walker. She does not require the intensity of 
services provided at an IRF. Specifically, the enrollee is not shown to require 15 hours per week of 
rehabilitative services and regular physician evaluation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that the therapist has done an 
assessment, but more therapy was denied. The Plan denied your request. The Plan says additional visits are 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 10 additional 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 that the unique skills of a professional 
therapist are not required to safely and effectively provide ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation of a portable x-ray (R0070) provided on 
May 27, 2020. 
 
You asked the Plan to pay for the transportation of a portable x-ray. You say that this is supported by the 
records. The Plan denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures involving fluoroscopy and procedures 
requiring the administration of a substance to the patient or injection of a substance into the patient and/or 
special manipulation of the patient are not covered under the portable x-ray provision. 
 
We looked at the file and Medicare rules. The records show that the service at issue included intermittent 
flouroscopic exposure and various barium infused liquids and solids by mouth. It is therefore not covered under 
the portable x-ray provision. Based on this information, we decided that Medicare rules for coverage of the 
transportation of a portable x-ray have not been met. Therefore, we decided that the Plan does not have to pay 
for the transportation of a portable x-ray (R0070) provided on May 27, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you could have the care they need at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $167.12 cost share applied to the deductible for out of 
network services provided on June 25, 2020. 
 
You asked the Plan to waive this cost share. You say that the Plan should cover this cost share. The Plan denied 
your request. The Plan says this cost share was applied per your Plan contract agreement. 
 
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 there is deductible for 2020. This cost sharing is a contractual obligation that 
had not been met at the time this cost share was received on June 25, 2020. Therefore, we decided that the Plan 
does not have to waive the $167.12 cost share applied to the deductible for out of network services provided on 
June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for antibody to human leukocyte antigens testing services (CPT 
86832 and CPT 86833) provided to the enrollee on March 3, 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 these services are not reimbursable when submitted with the professional component (modifier 
26). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 86832: 
 
Antibody to human leukocyte antigens (HLA), solid phase assays (e.g., microspheres or beads, ELISA, Flow 
cytometry); high definition qualitative panel for identification of antibody specificities (e.g., individual antigen 
per bead methodology), HLA Class I. 
 
CPT 86833: 
 
Antibody to human leukocyte antigens (HLA), solid phase assays (e.g., microspheres or beads, ELISA, Flow 
cytometry); high definition qualitative panel for identification of antibody specificities (e.g., individual antigen 
per bead methodology), HLA Class 2. 
 
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found CPT codes 
86832 and 86833 per the Medicare Claims Processing Manual are not payable when they are submitted with an 
appended 26 modifier or a TC modifier. 
 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for antibody to human leukocyte antigens testing services (CPT 86832 and CPT 86833) provided to 
the enrollee on March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (CPT 99152) provided to the 
enrollee. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99152 (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 code 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15minutes of intraservice time, patient age 5 
years or older." 
 
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 not supported by the medical records. Our physician reviewer found while 
the procedure note indicates that moderate sedation was provided, the procedure note does not indicate the 
presence of an independent observer, who monitored the patient while the physician performed the procedure.  
Furthermore, separate records, which may support the presence of an independent observer (i.e. nursing flow 
sheet, anesthesia records), have not been submitted for review. Therefore, the billing of CPT 99152, which 
requires the presence of an independent observer, cannot be supported. 
 
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 pay for moderate sedation services (CPT 99152) provided to the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucemyra. 
 
You asked the Plan to pre-approve Lucemyra. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Lucemyra.  
 
Benefits for Lucemyra 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, genetic testing, is being requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. The file shows that you are requesting the testing for a family 
history of cancer but do not have a personal history of cancer. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical connection for a power wheelchair. 
 
You asked the Plan to pre-approve the accessory. You say that this is medically necessary. The Plan denied 
your request. The Plan says  the electrical connection between the wheelchair controller and two or more 
motors (E2311) cannot be covered. 
 
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 accessory. Our reviewer says that 
the requested accessory is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the E2311 is not medically necessary. The documentation does not reveal that you need to 
operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate 
control devices),other electronic devices (e.g., control of an augmentative speech device or computer through 
the chair's drive control), or an attendant control. Your upper extremity strength and function are sufficient for 
 
 
you to control any power options through their own individual switches. 
 
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 accessory have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electrical connection for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture and a complete 
mandibular denture. 
 
You asked the Plan to pre-approve the complete maxillary and mandibular dentures. You say that you need 
these dentures because you are unable to eat. The Plan denied your request. The Plan says these services are not 
a covered benefit under your 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 pre-approve a 
complete maxillary denture and a complete mandibular denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure 
device (CPAP) and heated humidifier. 
 
You asked the Plan to pre-approve continued CPAP use. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that the enrollee did not tolerate a CPAP. 
 
The Plan must follow Medicare rules. Medicare rules say that you must use the PAP 4 hours per night on 70% 
of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. 
 
We looked at the file and Medicare rules. The compliance report included with the file indicates the enrollee 
did not adhere to therapy. Based on this information, we decided that Medicare rules for coverage of continued 
CPAP use have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use 
of a continuous positive airway pressure device (CPAP) and heated humidifier.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires daily rehabilitation services. 
The Plan denied your request. The Plan says the enrollee's needs can be met in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of 
rehabilitative services with regular physician evaluation.  The enrollee's care needs can be met at a lower level 
of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
(D6010). 
 
You asked the Plan to pre-approve the endosteal implant. The Plan denied your request. The Plan says this 
service is not a covered benefit. 
 
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 a 
surgical placement of implant body: endosteal implant (D6010).