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

 
We decided that the Plan does not have to pre-approve a Group 3 heavy-duty power wheelchair with power tilt, 
recline and elevating leg rests. 
 
You asked the Plan to pre-approve a Group 3 heavy-duty power wheelchair. You say that you cannot get from 
one room to the next without a Group 3 heavy-duty power wheelchair with power tilt, recline and elevating leg 
rests. The Plan denied your request. The Plan says the requested power tilt, recline and elevating leg rests 
exceeds your needs for mobility and positioning. 
 
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 Group 3 heavy-duty power 
wheelchair. Our reviewer says that the requested power wheelchair is not medically necessary. Our physician 
reviewer found a Functional Mobility & Wheelchair Assessment was performed on June 4, 2020. The enrollee 
is a non-functional ambulator, with a history of falls. The enrollee transfers independently and the current 
manual wheelchair is too low for access to counters and appliances. The documentation does not support that 
the enrollee is at high risk for development of a pressure ulcer and is unable to perform a functional weight 
shift; or utilizes intermittent catheterization for bladder management and is unable to independently transfer 
from the wheelchair to bed; or the power seating system is needed to manage increased tone or spasticity. The 
enrollee does not meet the requirement for power tilt, recline, and elevating leg rests. 
 
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 Group 3 heavy-duty power wheelchair with power tilt, recline and elevating 
leg rests have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 heavy-
duty power wheelchair with power tilt, recline and elevating leg rests.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve standard wheelchair (K0001). 
 
You asked the Plan to pre-approve the standard wheelchair. You say that the durable medical equipment is 
medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
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 standard wheelchair have not been met. The request is being 
denied at this time because the clinical information did not support the medical necessity for this service. The 
Plan needs copies of your doctor's office notes to document your condition and functional status. Please contact 
your Primary Care Provider to discuss the options that may be available, and if the Plan receives more 
information as part of a new request, the Plan will use it to evaluate the request. Therefore, we decided that the 
Plan does not have to pre-approve standard wheelchair (K0001).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve standard wheelchair (K0001). 
 
You asked the Plan to pre-approve standard wheelchair. You say that you have severe neuropathy on both legs 
and feet that is getting worse and you are not able to walk due to hammer toe on the right foot. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
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 standard wheelchair. Our physician 
reviewer found the documentation does not support that the enrollee in this case has a mobility limitation or 
other condition that significantly impairs her ability to participate in one or more 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 standard wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve standard wheelchair (K0001).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance (eg, proton) imaging (MRI), spinal 
canal and contents, lumbar; without contrast material (72148). 
 
You asked the Plan to pre-approve the MRI. You say that you were seeing a therapist several years ago. You 
state your therapy was discontinued, as it was no longer relieving your pain, but aggravating your injury. You 
state you moved to the east side of the state and you have had to re-establish your medical providers. The Plan 
denied your request. The Plan says the imaging is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our physician reviewer found 
you have a history of low back pain and surgery for spinal stenosis. You are having radicular pain in the right 
leg. No neurologic examination was documented. No red flag concerns were documented. You have not had 
any recent conservative therapy. An MRI is not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance (eg, proton) imaging (MRI), spinal canal and contents, lumbar; without 
contrast material (72148).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve genicular radiofrequency ablation. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested 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 genicular radiofrequency ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have chronic right knee pain after having a right knee replacement. 
You are taking Tramadol, Celebrex and Lidocoane Patches. The requested service is considered an 
experimental/ investigational procedure that is the subject of on-going clinical trials. Therefore, you do not 
meet criteria for the requested 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 genicular radiofrequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve genicular radiofrequency ablation (RFA).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on April 23, 
2020. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you switched plans but never 
paid for laboratory services before and disagree with the charges. 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 a $5 
copayment for laboratory tests.  
 
You have been asked to pay a $5 copayment for laboratory services. Laboratory services fall within the 
outpatient diagnostic tests and therapeutic services and 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 copayment for laboratory services provided on April 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital visit provided on 
October 25, 2019. 
 
You asked the Plan to waive the copayment for an outpatient hospital visit. You say that you disagree with the 
charges. 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 a $400 
copayment for each outpatient hospital facility visit.  
 
You have been asked to pay a $400 copayment for an outpatient hospital visit. An outpatient hospital visit falls 
within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers 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 outpatient hospital visit 
provided on October 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services other than manual manipulation of the 
spine provided from February 19, 2020 to February 27, 2020. 
 
You asked the Plan to pay for chiropractic services not related to manual manipulation. You say that these 
services should be covered by the Plan. The Plan denied your request. The Plan says only those services related 
to manual manipulation of the spine are covered when provided by a chiropractor. 
 
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 service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic 
services other than manual manipulation of the spine provided from February 19, 2020 to February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for provider visit. You say that the facility requested this visit, therefore medical necessity is pre-established for care. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the enrollee could have been treated by an in-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 medical services provided on May 11, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy visit provided on April 
23, 2020. 
 
You asked the Plan to waive the copayment for the physical therapy visit. You say that your financial situation 
will not allow you to afford the copayment. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing 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 a $40 
copayment for in-network Medicare-covered physical therapy and speech therapy.  
 
You have been asked to pay a $40 copayment for the physical therapy visit. The physical therapy visit falls 
within the Outpatient rehabilitation 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 physical therapy visit provided on April 23, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a repeat radiofrequency ablation.

You asked the Plan to pre-approve a repeat radiofrequency ablation. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested 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 a repeat radiofrequency ablation. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic neck pain. The enrollee had prior radiofrequency ablation of the cervical medical branch blocks in 2016 which provided over two years of pain relief. The enrollee had repeat dual diagnostic medical branch blocks in August 2019. There is no peer reviewed paper or clinical guideline that states that due to the diagnostic medial branch blocks were performed more than three months prior to the proposed radiofrequency ablation, that those results are no longer valid and radiofrequency ablation isn't indicated. Therefore, the requested procedure is medically reasonable and necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a repeat radiofrequency ablation have been met. Therefore, we decided that the Plan has to pre-approve a repeat radiofrequency ablation. 

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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan. 
 
You asked the Plan to pre-approve a CT scan. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan. Our reviewer says that the 
documentation does not support that the requested CT scan is medically reasonable or necessary. Our physician 
reviewer found the enrollee was diagnosed with stage III esophageal adenocarcinoma and is status post 
tranhiatal esophagectomy. a CT was performed on April 27, 2020 without significant abnormality. Repeat 
imaging is recommended every 6 months for two years per guidelines. Therefore, the enrollee does not meet 
criteria for the requested 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 a CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a CT scan.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insulin (J1815) provided on April 2, 2020. 
 
You asked the Plan to pay for the insulin. You say that insulin injections were the only practical method of 
caring for your health due to your diabetic condition. The Plan denied your request. The Plan says this drug is 
self-administered and not covered by Part B. 
 
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 the insulin (J1815) provided on 
April 2, 2020.  
 
Benefits for the insulin 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 pay for laboratory services provided on December 11, 2019. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the enrollee 
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan.  
 
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 did not pre-approve the 
laboratory services. 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 laboratory services provided on December 11, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 24, 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 the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 pay for the Guardant360 panel rendered on March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99232) provided on November 2, 2019. 
 
You asked the Plan to pay for hospital care. You say that this was denied in error. The Plan denied your 
request. The Plan says this is included in the global surgical package of another procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that there is no separate payment for postoperative 
visits or services within 10 days of the surgery that are related to recovery from the procedure. Two CPT 
modifiers were established to simplify billing for visits and other procedures which are furnished during the 
postoperative period of a surgical procedure, but which are not included in the payment for the surgical 
procedure. 
 
We looked at the file and Medicare rules. The record shows that a drainage procedure, 10061, which has a 
global period of 10 days, was performed on October 24, 2019. The hospital care at issue was not billed with a 
modifier that indicates it was an unrelated service.  
 
Based on this information, we decided that Medicare rules for coverage of hospital care have not been met. 
Therefore, we decided that the Plan does not have to pay for hospital care (99232) provided on November 2, 
2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
August 15, 2019. 
 
You asked the Plan to pay for genetic testing. You say that this testing was ordered by the treating physician to 
determine the optimal treatment pathway for the enrollee. The Plan denied your request. The Plan says the 
denial of payment for this testing is correct, because this testing was not billed with the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 
for date of service August 15, 2019.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
comprehensive genomic profile (CGP) testing provided on August 15, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services 
provided from November 1, 2019 to November 21, 2019. 
 
You asked the Plan to waive the copayment for the SNF services. The Plan denied your request. The Plan says 
that the claims processed 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 $100 
copayment per day for days 21-100 of SNF care.  
 
You have been asked to pay a $800 copayment for the SNF services. The file indicates you were in a SNF from 
October 23, 2019 through November 21, 2019, for a total of thirty (30) days. The SNF services falls within the 
days 21-100 of SNF care benefit category. You owe a copayment for days 21-30 of SNF care. This means that 
you have been asked to pay less than 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 skilled nursing facility (SNF) services provided from November 
1, 2019 to November 21, 2019.