Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10mg escitalopram tablets. 
 
You asked the Plan to pre-approve 10mg escitalopram tablets. The Plan denied your request. The Plan says this 
medication does not fall under Part B 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 10mg escitalopram tablets.
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 the SNF services. You say that the enrollee is only able to stand with a walker and is unable to walk. You say that the last time the enrollee was discharged, she fell 2 days later. You say that the enrollee's low potassium is causing her muscle weakness, so this needs to be monitored. The Plan denied your request. The Plan says the enrollee is at or near the baseline level of function based on the previous level of function. The Plan says that the enrollee's needs can be met at a lower level of care with skilled therapy 3-4 times per week and daily non-skilled caregiver support. Otherwise, the Plan says that the enrollee's needs are custodial in nature.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and clear lungs. The enrollee was at a minimal assist to contact guard assist level with functional mobility. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee does not meet the 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 the 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty power operated vehicle (K0801). 
 
You asked the Plan to pre-approve a heavy-duty power operated vehicle. You say that this item is needed due 
to your medical conditions. The Plan denied your request. The Plan says this item is not covered for your 
weight. 
 
The Plan must follow Medicare rules. The rules state that a heavy-duty power operated vehicle is for patients 
that weigh between 285-400 pounds. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heavy-duty power operated vehicle have not been met. Specifically, this item is covered for 
patients in the weight range of 285-400 pounds. The record indicates that you are not within this weight range. 
Therefore, we decided that the Plan does not have to pre-approve a heavy-duty power operated vehicle 
(K0801).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that you are unable to get upstairs. 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 stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift 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 stair glide.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the circumcision (54161) provided on July 31, 2020. 
 
You asked the Plan to pay for the circumcision. You say that you would like reconsideration because the 
services of the assistant surgeon were medically necessary. The Plan denied your request. The Plan says CPT 
code 54161 has an Assistant Surgery indicator of ?1? which does not allow assistant surgeon payment. 
 
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 
54161. 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. Based 
upon this information, we find that Medicare coverage criteria for the circumcision have not been met. 
Therefore, we decided that the Plan does not have to pay for the circumcision (54161) provided on July 31, 
2020.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve hyperbaric oxygen therapy (HBOT).
You asked the Plan to pre-approve the HBOT. You say that you are confined to a wheelchair and cannot walk or stand. You say that you have wound care treatments done 3 times per week and you go to the doctors at least 2-3 times per month. You say that you are fearful of losing your right leg because you are being denied treatment that could help health the wounds. You say that you cannot continue compression therapy right now because the wounds cause great discomfort. You say that the requested HBOT would enable you to return to some normalcy in your life. The Plan denied your request. The Plan says that the enrollee's diagnosis is not a covered condition for HBOT.
The Plan must follow Medicare rules. Medicare rules say that HBO therapy is a valuable adjunctive treatment to be used in combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened. Medicare rules say that items or services will be covered when 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 HBOT. Our reviewer says that HBOT is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has non-healing venous stasis ulcers that have failed quite extensive conventional therapy. The enrollee is at risk for limb loss. HBOT is beneficial in therapy for non-healing wounds due to inadequate perfusion. 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 HBOT have been met. Therefore, we decided that the Plan has to pre-approve hyperbaric oxygen therapy (HBOT).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on July 1, 
2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you feel you should not 
be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received ambulance services on the date of service at issue in this 
appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $250 
copayment for Ambulance Services.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received ambulance 
services on July 1, 2020. You have been asked to pay a $250 copayment for the ambulance services. The 
ambulance services fall within the Ambulance 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 ambulance services provided on July 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (87624, 88142) provided on September 11, 
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 the services were not emergent or pre-authorized. There were network 
providers available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the lab services (87624, 88142) provided on September 11, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating 
provider on July 20, 2020, to August 10, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you were told that it would be 
covered. You say that you should only have a $30 copayment. The Plan denied your request. The Plan says the 
correct copayment has been applied. 
 
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 $160 
copayment for outpatient diagnostic tests/radiological diagnostic services.  
 
You have been asked to pay less than a $160 copayment for each ultrasound. You have been asked to pay 
$148.87 for each ultrasound. The total amount you are being asked to pay is $595.48 ($148.87 x 4 ultrasounds 
= $595.48). An ultrasound falls within the outpatient diagnostic tests/radiological diagnostic 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 an ultrasound provided by a participating 
provider on July 20, 2020, to August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services (73560, 20610, J1040) provided on 
May 7, 2020. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not emergent or pre-authorized. There were network 
providers available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the physician services (73560, 20610, J1040) provided on May 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the new patient office or other outpatient visit (99204)
to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the new patient office or other outpatient visit. You say that you do not feel
comfortable using the Plan's contracted provider. The Plan denied your request. The Plan says they have
multiple in-network providers available for your medical needs.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
the new patient office or other outpatient visit (99204) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve the power wheelchair. You say that the mobility scooter being requested is 
for use both inside and outside of your home. You say that use of the mobility device begins inside the home, 
where you can take better care of yourself and your home without causing pain and while reducing the 
possibility of falling. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
coverage of a power scooter. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. The medical records provided from the face-to-
face evaluation with the home physical therapist clearly show that you are able to ambulate in your home with 
a cane and rollator for balance and support. The medical records also show that the primary intention is to use 
the power wheelchair outdoors in the community. Although this item may be helpful, neither Medicare nor the 
Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-
approve a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) rendered by the 
out of network (OON) provider on February 5, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the hospital outpatient clinic visit (G0463) rendered by the out of network (OON) provider on 
February 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional 33 units of CPT 86003 provided to you on 
October 4, 2019. 
 
You asked the Plan to pay for the additional units. You say that this should be covered in full. The Plan denied 
your request. The Plan says this exceeds the benefit limit. 
 
The Plan must follow Medicare rules. Medicare rules say that in vitro testing will be covered for only thirty 
(30) units per year for medically reasonable and necessary indications as outlined in this LCD. Services 
exceeding this parameter will be considered not medically necessary.  
 
We looked at the file and Medicare rules. The records show that you were provided 63 units of CPT 86003. 
Only 30 units of this service are covered per year. The additional 33 units exceed the coverage limit and are 
considered not medically necessary. Based on this information, we decided that Medicare rules for coverage of 
the additional units have not been met. Therefore, we decided that the Plan does not have to pay for the 
additional 33 units of CPT 86003 provided to you on October 4, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on July 2, 2019 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were 
neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 had network providers 
available who could have provided 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 outpatient hospital services provided on July 2, 
2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epoetin alfa. 
 
You asked the Plan to pre-approve Epoetin alfa. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the records do not support the need for the drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Epoetin alfa. Our reviewer says that the 
medical records do not support the need for Epoetin alfa. Our physician reviewer found that the enrollee has a 
hemoglobin level of greater than 10 g/dL and does not have a ferritin of more than 100 ng/mL prior to therapy. 
Our reviewer says that the documentation does not support that the Epoetin alfa is medically reasonable or 
necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Epoetin alfa have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Epoetin alfa.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram interpretation and report (93010) 
provided on June 19, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service provided was not medically 
necessary. 
 
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 93010 is Electrocardiogram, routine ECG with at least 12 
leads; interpretation and report only. 
 
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 this service. Our reviewer says that this code 
does not meet criteria for coverage. Our physician reviewer found that the documentation did not include a 
diagnosis to support an electrocardiogram. Medical preoperative examinations and diagnostic tests done by, or 
at the request of, the attending surgeon will be paid by Medicare, assuming the carrier determines the services 
to be medically necessary. All claims must be accompanied by the appropriate ICD 10 code for preoperative 
examination. The ICD 10 code for the condition that prompted surgery should be documented on the claim. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pay for the electrocardiogram interpretation and report (93010) provided on June 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the commode chair with CPT code E0165 provided on June 
25, 2020. 
 
You asked the Plan to pay for CPT code E0165. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that capped rental items are paid on a monthly rental 
basis. 
 
Code E0165 is designated as capped rental in the durable medical equipment (DME) fee schedule. The DME 
fee schedule also does not provide a listing for items billed with E0165-NU-KX. As such, this item cannot be 
paid as billed. Code E0165 has not been billed with the correct modifier. Therefore, we decided that the Plan 
does not have to pay for the commode chair with CPT code E0165 provided on June 25, 2020.