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

 
We decided that the Plan does not have to pre-approve a power scooter for the enrollee. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has been no face-to-face evaluation, no specialty evaluation, and home evaluation 
as required by Medicare rules. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found there is no 
documentation of a personal mobility deficit that impairs participation in mobility related activities of daily 
living (MRADLs). There is no documentation that the enrollee's deficit cannot be helped by the use of walker, 
cane, or manual wheelchair. There is no documentation that the enrollee would be able to safely operate the 
scooter. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on April 13, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says code 81298 was denied because the appropriate lab test was not reported in the previous 
thirty days. The Plan states there are no prior claims on file with the required primary procedure code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case the claim submitted cannot be paid as the 
appropriate procedure code was not reported. Medicare billing criteria are not met. Therefore, we decided that 
the Plan does not have to pay for lab services provided to the enrollee on April 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Gel-One injection. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medical information received does not show a steroid injection in the past. 
 
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 the injection. Our reviewer says that the 
requested injection is not medically reasonable or necessary. Our physician reviewer found there is no 
documentation of an inadequate response/intolerance/contraindication to a trial of intraarticular steroid 
injections for at least three months. The review has determined that the requested Gel-One injection is not 
medically reasonable or 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Gel-One injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan. 
 
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 the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 
the services are not medically necessary. Our physician reviewer found the enrollee is noted to have 
rheumatoid arthritis and inflammatory polymyositis. She has not tried and failed the Plan's required drugs of 
TNF therapies (Humira, Enbrel, or Remicade). The records do not show that the required drugs would be 
contraindicated or less effective; therefore, Rituxan is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Rituxan.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sleep study, unattended, simultaneous recording of, 
heart rate, oxygen saturation, respiratory airflow, and respiratory effort (eg, thoracoabdominal movement) 
(CPT Code 95806) 
 
You asked the Plan to pre-approve the service. You say that you have sleep apnea and are having trouble 
sleeping throughout the night. The Plan denied your request. The Plan says the information did not show that 
you suffer from obesity, witnessed apnea or snoring to support medical necessity of a sleep study in a lab 
setting. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. There were no medical records 
provided to verify why you need this service. Therefore, we decided that the Plan does not have to pre-approve 
sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and 
respiratory effort (eg, thoracoabdominal movement) (CPT Code 95806)
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on August 16, 2020 in the 
emergency room. 
 
You asked the Plan to pay for self-administered drugs. You say that this bill should be paid by the Plan. The 
Plan denied your request. The Plan says payment for self-administered drugs should be submitted to your 
Medicare Part D carrier. 
 
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 pay for self-administered drugs provided 
on August 16, 2020 in the emergency room.  
 
Benefits for self-administered drugs 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: 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 a power wheelchair. You say that the enrollee does not have the arm 
strength to use the manual wheelchair. The Plan denied your request. The Plan says it is not clear that the 
enrollee's mobility limitations could not be resolved with the use of a cane, walker, or manual wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a power wheelchair. Our physician 
reviewer found that you have a personal mobility deficit, but the treating medical practitioner notes are not 
clear that this deficit impairs participation in MRADLs in the home. The documentation does not reveal why 
your mobility deficit is unable to be helped with a manual wheelchair to perform MRADLs in the home. There 
is no detailed gait or neuromuscular exam in the progress notes. The documentation is not clear that you can 
safely maneuver the power operated vehicle  in the home, or that the requested power wheelchair will 
significantly improve ADL performance 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 a power wheelchair have not been met. 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 waive the $50 cost share (20% coinsurance) charged for imaging 
services and supplies provided on February 26, 2020. 
 
You asked the Plan to waive this copayment. You say that this copayment is not correct. The Plan denied your 
request. The Plan says the provider billed procedure code A9552 in the amount of $625.00. The allowed 
amount for procedure code A9552 is $250.00. The plan applied 20% to procedure code A9552 for a 
coinsurance in the amount of $50.00.  
 
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 Medicare covered supplies. 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 $50 cost share (20% coinsurance) charged 
for imaging services and supplies provided on February 26, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $90 copayment charged for emergency room services 
provided on July 27, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct or that 
you are responsible for it. The Plan denied your request. The Plan says this copayment was charged based on 
the services provided and the Plan contract agreement. 
 
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 $90 
copayment for emergency room services.  
 
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 $90 copayment charged for emergency room services provided on July 27, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided to the enrollee on July 16, 2020 and 
billed under code 94799. 
 
You asked the Plan to pay for code testing provided to the enrollee. You say that this claim should be paid. The 
Plan denied your request. The Plan says the records show the intent of the code was for oxygen titration. It 
appears a pulmonary stress test was performed, with notes showing patient?s oxygen level, ambulate time and 
mph for a total of 6 minutes. There is a more appropriate code for a pulmonary stress test. Therefore, code 
94799 remains denied.  
 
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, based on the records provided, a 
more appropriate code is required instead of the use of 94799. Medicare billing criteria are not met. Therefore, 
we decided that the Plan does not have to pay for testing services provided to the enrollee on July 16, 2020 and 
billed under code 94799.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray provided on February 4, 2020. 
 
You asked the Plan to pay for the x-ray. You say that the enrollee was not enrolled in hospice on the date of 
service. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the 
member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 3, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the chest x-ray 
provided on February 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where they are currently receiving care. There are 
no required medical services identified that are available at the LTACH, that are not available at the current 
health care setting being offered by the health plan. The documentation does not support that an additional 25 
days of hospitalization are reasonably expected for the enrollee in this case. Consequently, the requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a PET scan. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found per CMS specific regulations for prostate 
cancer the enrollee does not have an indication for a PET scan at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient rehabilitation services provided 
from October 12, 2019, to October 26, 2019. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that you thought 
there was zero copayment for the inpatient services. The Plan denied your request. The Plan says you were 
charged the cost share correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment per day for days 1-7 for Inpatient Hospital Care.  
 
You have been asked to pay a $250 copayment per day for days 1-7 for the inpatient services. The inpatient 
services fall within the Inpatient Hospital 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 inpatient rehabilitation services provided from October 12, 2019, to October 26, 2019.
Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to pay for CPT codes 31295 and 31298. We decided that the Plan does not have 
to pay for CPT code 30117.  
 
You asked the Plan to pay for CPT codes 31295, 31298 and 30117. You say that the medical records support 
the billing of CPT codes 31295, 31298, and 30117. The Plan says that the medical records do not support the 
billing of CPT codes 31295, 31298, and 30117. 
 
We decided that the Plan has to pay for CPT codes 31295 and 31298.  
 
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 31295 is Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, 
transnasal or via canine fossa. The CPT Code Manual definition of code 31298 is Nasal/sinus endoscopy, 
surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus ostia. 
 
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 CPT codes 31295 and 31298. Our reviewer 
says that the medical records support the billing of CPT codes 31295 and 31298. Our physician reviewer found 
the enrollee is with diagnoses of Headache, chronic ethmoidal sinusitis, hypertrophy of nasal turbinates and 
chronic maxillary sinusitis, Chronic frontal sinusitis, Chronic sphenoidal sinusitis, and Polyp of nasal cavity. 
The medical records support both the billing of CPT codes 31295 and 31298. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPT codes 31295 and 31298 have been met. Therefore, we decided that the 
Plan has to pay for CPT codes 31295 and 31298.  
 
We also decided that the Plan does not have to pay for CPT code 30117. 
 
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 30117 is Excision or destruction (eg, laser), intranasal lesion; internal approach. 
 
We find that CPT code 30117 is not supported in the medical record. Specifically, CPT code 30117 has a 
bilateral surgery indicator of ?0?. Based on this information, we decided that Medicare rules for coverage of 
CPT code 30117 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 
30117. 
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is 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 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
resides in a skilled nursing facility receiving therapy services for weakness after recent back surgery. Medical 
conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing 
or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on June 30, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 70450 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 70450 and 70496. Code 70450 is a column II code with a 
modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the 
computed tomography (CT) scan of the head/brain rendered on June 30, 2020.