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

We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with single power
option (K0856) and related accessories and features.
You asked the Plan to pre-approve a Group 3 standard power wheelchair and related accessories. You say that
the requested power wheelchair is a medical necessity for you. The Plan denied your request. The Plan says
medical-necessity rules for coverage of the requested power wheelchair have not been met.
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 standard power wheelchair
and related accessories. Our reviewer says that a power wheelchair is not medically reasonable and necessary
in this case. Our physician reviewer found no evidence that you are able to safely operate a motorized
wheelchair.
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 standard power wheelchair have not been met. Because the base item
cannot be covered, the related accessories are also not covered. Therefore, we decided that the Plan does not
have to pre-approve a Group 3 standard power wheelchair with single power option (K0856) and related
accessories and features.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 95 out-of-network (OON) endocrinologist visits. 
 
You asked the Plan to pre-approve out of network care. The Plan denied the request for 99 visits. The Plan 
approved four to allow transition into the network from June 27, 2022, to September 27, 2022. The remaining 
95 visits have been denied because these services can be provided in-network. The Plan has provided a list of 
physicians and staff who can treat the enrollee in-network.  
 
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 provider in this case is not a network provider with the Plan. The Plan has provided a list of network 
providers available who can treat the enrollee.  We found no exception that would require the Plan to pre-approve these services on a continual basis out of 
network. The Plan has allowed four visits to give the enrollee time to transition with an in-network provider. 
Therefore, we decided that the Plan does not have to pre-approve 95 out-of-network (OON) endocrinologist 
visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transcutaneous electrical nerve stimulation (TENS) device 
(E0730) and related supplies (A4595) provided on February 24, 2022. 
 
You asked the Plan to pay for a TENS device and related supplies. You say that the item at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have 
not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided on the date of service at issue in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for a transcutaneous electrical nerve 
stimulation (TENS) device (E0730) and related supplies (A4595) provided on February 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 18, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gradient compression wrap provided on March 25, 2021. 
 
You asked the Plan to pay for the services provided. You say that active ulcers is a required diagnosis for this 
item. The Plan denied your request. The Plan says the service is non-covered.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code A6545 was billed with a -GY modifier. Claim lines billed with this modifier are 
automatically denied. Based on this information, we decided that Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pay for the gradient compression wrap provided on 
March 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of procedure code 81465 billed for date of service 
February 22, 2022. 
 
You asked the Plan to pay for two units of code 81465. You say that these services are supported in the medical 
records. The Plan denied your request. The Plan says Medicare rules state that this service may only be billed 
for one unit per day.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 81465 is 1. The MAI value for this code is 2. You billed two (2) units of 
this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of two 
units of code 81465 have not been met. Therefore, we decided that the Plan does not have to pay for two units 
of procedure code 81465 billed for date of service February 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray and contrast injection rendered on April 14, 2022. 
 
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 is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 4, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the x-ray and contrast injection rendered on April 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis provided on February 
16, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for targeted genomic sequence analysis. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says although the original claim denial was for 
not meeting Medicare NCD/LCD criteria, the services are not authorized because the provider is a non-network 
provider who does not work with the members health 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 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 targeted genomic sequence analysis provided on 
February 16, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service March 27, 
2022. 
 
You asked the Plan to pay for procedure code 99233. You say that this was a different provider with a different 
taxonomy number on this date. You say that the claim should be reprocessed. The Plan denied your request. 
The Plan says a modifier is not allowed with this code pair. 
  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, we have confirmed that code 99233 
is a column II code to column I code 99223 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99233 billed for date of service March 27, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on January 18, 
2022, to March 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
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 outpatient mental health services provided on 
January 18, 2022, to March 15, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 11, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the laboratory does not have 
an agreement with the dialysis facility which indicates that these services are billed with the dialysis rate. The 
Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed.  
 
 
 
 
 
  
 
Therefore, we decided that the Plan does not have to pay for the laboratory services related to end-stage renal 
disease (ESRD) provided on February 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service March 26, 
2022, to April 22, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that S9328 is billed for each 24-hour period the 
enrollee is provided with implanted pump pain management infusion. You say that S9328 is payable, and the 
claims should be reprocessed for payment. The Plan denied your request. The Plan says the billed code is 
invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 
  We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service March 26, 2022, to April 22, 2022.
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 need more help than is being provided at the 
current skilled nursing facility. The Plan denied your request. The Plan says you do not meet criteria for IRF 
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 in the Medicare rules section. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on April 6, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical supplies provided on March 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for medical supplies. You say that the medical supplies were referred by your PCP. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 medical supplies provided on March 10, 2022, by 
an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room visit provided on February 18, 2022. 
 
You asked the Plan to pay for the services provided. You say that the chart coded correctly. The Plan denied 
your request. The Plan says the billing requires multiple diagnoses. 
 
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 99283 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: An expanded problem focused history; 
An expanded problem focused examination; and medical decision making of moderate complexity. Counseling 
and/or coordination of care with other physicians, other qualified health care professionals, or agencies are 
provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the 
presenting problem(s) are of moderate severity. 
 
 
 We find that CPT code 99283 is not supported in the medical record. The records show that the enrollee 
presented to the emergency room with urology referral issue. The exam was unremarkable. The records do not 
show the enrollee presented with a problem of moderate severity. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the emergency room visit provided on February 18, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for opioid treatment visits provided from February 27, 2022, to March 27, 
2022. 
 
You asked the Plan to pay for opioid treatment visits. You say that this claim was denied in error. The Plan 
denied your request. The Plan says that the denial of payment for these services is correct, because the claim 
does not meet the opioid treatment program criteria for payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan claims that these services do not meet payment criteria; however, the 
Plan has not provided any specific rationale or evidence to support that claim. Therefore, the Plan has not 
shown that its decision to deny payment for these services is correct or justified according to Medicare rules. 
Therefore, we decided that the Plan has to pay for opioid treatment visits provided from February 27, 2022, to 
March 27, 2022.  
 
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: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the Palonosetron injection provided on October 21, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the 
documentation does not support 10 units on the date of service. 
 
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 J2469 is injection, palonosetron hcl, 25 mcg. We find that 
CPT code J2469 is supported in the medical record. We find that 25 micrograms (mcg) are equivalent to 0.025 
milligrams (mg). The records show that a Palenosetron injection of 0.25 milligrams was provided. This means 
that 10 units of Palonosetron 25mcg was provided. Based on this information, we decided that Medicare rules 
for coverage of the services provided have been met. 
 
The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the 
IRE information regarding its decision to deny coverage or payment. The plan listed codes 96361, 96375, 
96413, and 96417 as non-appealable. The Plan has not made reasonable and diligent efforts to gather and 
forward to us information regarding their decision. Therefore, we decided that the Plan has to pay for the 
Palonosetron injection provided on October 21, 2021.  
 
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.