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

 
We decided that the Plan does not have to pay for the infusion services provided on December 31, 2021. 
 
You asked the Plan to pay for the services provided. You say that this plan is the payer on record. The Plan 
denied your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code J7040 is Infusion, normal saline solution, sterile (500 ml 
= 1 unit). We find that CPT code J7040 is a packaged item. Payment is packed into payment for other services. 
There is no separate payment.  
 
The CPT Code Manual definition of code M0247 is intravenous infusion, sotrovimab, includes infusion and 
post administration monitoring. Per the Centers for Medicare and Medicaid Services, claims for this service is 
billed to the Medicare Advantage plans on or after January 1, 2022. For Medicare Advantage patients you 
treated in 2021, submit claims for administering COVID-19 monoclonal antibody products to Original 
Medicare.  
 We looked at the file and the rules. 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 infusion services provided 
on December 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extremity study provided on December 29, 2021, by an 
out-of-network provider. 
 
You asked the Plan to pay for the extremity study. You say that this provider is a well-known respected 
cardiologist in your area so you decided to try him out. The Plan denied your request. The Plan says these 
services were provided by a non-contracted provider and were not authorized. 
 
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 extremity study provided on December 29, 
2021, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (85060) provided February 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 85060 is not supported in the medical record. Specifically, this code as a professional 
component / technical component of 8 and was billed with a place of service of outpatient hospital (22). When 
performed in the facility setting this service is not eligible for separate payment. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services (85060) provided February 22, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the magnetic resonance imaging (MRI) of the spine (72148) provided 
on June 27, 2019. 
 
You asked the Plan to pay for the MRI services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says that the services billed are not payable 
because the provider is not enrolled or accredited by a designated Centers for Medicare & Medicaid Services 
(CMS) accreditation organization. 
 
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. In this case, the Plan has denied coverage for payment of the MRI services 
stating that the provider as not enrolled or accredited by a designated CMS accreditation organization. 
However, the Plan has provided no evidence to back up this claim.  Therefore, we decided that the Plan has to 
pay for the magnetic resonance imaging (MRI) of the spine (72148) provided on June 27, 2019.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine trips. 
 
You asked the Plan to pre-approve additional mileage. The Plan denied your request. The Plan says 
transportation mileage is limited to 50 miles per one-way trip. The Plan also says that the distance exceeds the 
50 mile limit outlined in the 2022 Annual Notice of Changes. 
 
  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when the destination from the pickup location is within a 50 mile 
limit.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage for routine trips.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine (72148). 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. The Plan denied your request. The Plan says 
this cannot be approved because you have not completed six weeks of provider directed treatment, and the 
provider directed treatment did not occur within the last three months. The Plan also says that symptoms must 
be the same or worse after treatment to support imaging, and there was no contact with your provider after 
completing treatment. 
 
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 an MRI of the lumbar spine. Our 
reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found 
the physical therapy note from 2021 indicated that you were not adherent to the home exercise program (HEP). 
The current clinical assessment from May 3, 2022 did not document any exam abnormality: negative straight 
leg raise (SLR) and no abnormal neurological findings with strength. Our reviewer found that there is some 
limited range of motion (ROM) noted but not described. The plan was to increase your Tylenol along with the 
use of a Lidocaine patch and pain management referral. Our physician reviewer also found that there is no 
specific clinical rationale for an MRI of the lumbar spine. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care. 
The Plan denied your request. The Plan says the enrollee's care does not need to be managed by a rehabilitation 
doctor. The Plan says that the enrollee's treatment plan goals could be achieved in another setting. 
 
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 the enrollee is medically stable except confusion and does not need physical 
medicine and rehabilitation physician's supervision 3 times per week (at a minimum) for the ongoing 
management of any active or acute exacerbations of chronic medical conditions. There are no acute rehab 
nursing needs identified or documented. At the current functional level of contact guard assist, the enrollee 
does not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach in an IRF. An IRF admission is not medically necessary based on continued 
confusion and lack of acute rehabilitation nursing needs and high functional level. While the enrollee may 
benefit from continued physical therapy and occupational therapy, his rehabilitation needs can be safely 
provided in a lower intensity and alternate setting such as in a skilled nursing facility. 
 
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 pre-approve cervical/thoracic facet joint blocks. 
 
You asked the Plan to pre-approve cervical/thoracic facet joint blocks. You say that cervical/thoracic facet joint 
blocks are medically necessary. The Plan denied your request. The Plan says cervical/thoracic facet joint blocks 
are not medically necessary per the Medicare LCD. 
 
The Plan follows Medicare rules. 
 
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 cervical/thoracic facet joint blocks. Our 
reviewer says that cervical/thoracic facet joint blocks are not medically necessary. Our physician reviewer 
found that you have multiple other probable pain generators and therefore does not meet the Medicare LCD 
criteria. The request is considered 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 cervical/thoracic facet joint blocks have not been met. Therefore, we decided 
that the Plan does not have to pre-approve cervical/thoracic facet joint blocks.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for urology. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the provider is non-preferred for this request. 
 
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 
an out-of-network referral for urology.
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. The Plan denied your request. The Plan says services can safely 
be received in other settings. 
 
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 the enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these OON services. You say that you disagree with the plan's denial. The 
Plan denied your request. The Plan says the requested services can be provided by a 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 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 
an office visit 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 repairs for a power wheelchair. 
 
You asked the Plan to pre-approve power wheelchair repairs. 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 a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that payment cannot be made for repairs amounts that 
exceed the purchasing or renting of another item of equipment. 
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee has previously received 
repairs totaling $5,012.18. The cost for the requested repairs is $1588.70. The replacement cost of the power 
wheelchair is $5,600.05. This means the repair amount exceeds the replacement value. Payment for repairs 
cannot be made. Based on this information, we decided that Medicare rules for coverage of power wheelchair 
repairs have not been met. Therefore, we decided that the Plan does not have to pre-approve repairs for a power 
wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested items. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a power wheelchair and accessories is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve Freestyle Libre CGM. You say that you disagree with the plan's denial. The 
Plan denied your request. The Plan says you do not meet criteria for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of Freestyle 
Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle 
Libre continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing provided on September 9, 2021. 
 
You asked the Plan to pay for drug testing. You say that this testing was medically necessary. The Plan denied 
your request. The Plan says that the denial of payment for this testing is correct, because only 15 drug classes 
were counter in the lab results submitted which does not support code G0483. 
 
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 G0483 is drug test(s), definitive, qualitative or quantitative, all sources, includes specimen validity testing, 
per day; 22 or more drug class(es), including metabolites if performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the test results submit include 
more than 22 drug classes. Based on this information, we decided that Medicare rules for coverage of drug 
testing have been met. Therefore, we decided that the Plan has to pay for drug testing provided on September 9, 
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.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter (OTC) COVID-19 tests purchased on 
December 31, 2021. 
 
You asked the Plan to pay for the OTC COVID-19 tests. The Plan denied your request. The Plan says the OTC 
COVID-19 diagnostic tests denied correctly as neither Medicare nor the Plan provided coverage for this item 
prior to January 15, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that starting January 15, 2022, most people with a 
health plan can go online, or to a pharmacy or store to purchase an at-home over-the-counter COVID-19 
diagnostic test authorized by the U.S. Food and Drug Administration (FDA) at no cost. Therefore, we decided 
that the Plan does not have to pay for the over-the-counter (OTC) COVID-19 tests purchased on December 31, 
2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care discharge day management (99127) 
provided on December 3, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the services provided were 
medically necessary and rendered in good faith. The Plan denied your request. The Plan says the enrollees 
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 
providers responsibility to verify the enrollees 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for observation care discharge day management (99127) 
provided on December 3, 2021.