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

 
We decided that the Plan does not have to pre-approve a wig. 
 
You asked the Plan to pre-approve a wig. You say that the enrollee is on chemotherapy. The Plan denied your 
request. The Plan says the requested item is not a covered benefit. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (K0861, 
E2361x2, E1007, E0955, E1028, E2605, E1012, K0040, E2377, E2313, E2311, E1028). 
 
You asked the Plan to pre-approve the services. You say that the enrollee is unable to move room to room, 
bath, toilet, or dress herself safely without assistance. The Plan denied your request. The Plan says the enrollee 
does not have a medical need for multiple power options included with K0861 group 3 power 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 patients 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 services. Our reviewer says that the 
requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that the 
documentation does not reveal that the patient is at high risk for development of a pressure ulcer, utilizes intermittent catheterization for bladder management, or needs a power seating system to manage increased tone 
or spasticity. The patient does not use a ventilator mounted to the wheelchair. Therefore the request for the 
Group 3 power wheelchair with multiple power options of power and tilt exceeds the patient's medical needs. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair and accessories (K0861, E2361x2, E1007, E0955, E1028, 
E2605, E1012, K0040, E2377, E2313, E2311, E1028).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation services (99224) provided on January 6, 2021. 
 
You asked the Plan to pay for the observation services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the code 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. 
 
In this case, the CPT Code Manual definition of code 99224 is Subsequent observation care, per day, 
for the evaluation and management of a patient. 
 
We find that CPT code 99224 is not supported in the medical record. Specifically, the observation service was 
billed with an inappropriate place of service (21, inpatient hospital). Based on this information, we decided that 
Medicare rules for coverage of the observation services have not been met. Therefore, we decided that the Plan 
does not have to pay for observation services (99224) provided on January 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 31, 2022, billed with 
codes 81432 and 84133. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this test was not billed in 
accordance with Medicare rules and has not been evaluated by the Medicare MolDx program. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 31, 2022, billed with codes 81432 and 84133.
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 requested IRF admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no 
complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc. 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. 
 
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 Synvisc. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided and 
the Medicare-approved major drug compendia there is no indication that the plan's required drugs would likely 
be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral appliance. 
 
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 services from an opt-out provider are not covered. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pre-approve an 
oral appliance.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says based on 
Medicare guidelines the long term acute care hospital services you are requesting do not meet the requirements 
for approval. 
 
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 enrollee was admitted to the acute care hospital with pyelonephritis/urinary tract 
infection, treated with antibiotics and complicated by deep vein thrombosis and pulmonary embolism, atrial 
fibrillation with rapid ventricular rate, new onset ventricular cardiomyopathy, and malnutrition. Recent notes 
describe the enrollee as on Xarelto, no leukocytosis, with PICC line, tolerating room air, with stable vitals, 
resolved encephalopathy, and only requiring basic wound care.  
 
 The enrollee appears to be more stable and improving and should only require short term additional acute care 
services that can safely be provided at the current facility until more stable and appropriate for a lower level of 
care. The enrollee does not require services at the LTACH that are not already available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the patient lift rendered on April 9, 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 provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. The file shows that the provider was not Medicare-certified for the 
dates of service at issue. Therefore, we decided that the Plan does not have to pay for the patient lift rendered 
on April 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an automatic external defibrillator (K0606) provided on May 
23, 2021. 
 
You asked the Plan to pay for an automatic external defibrillator. You say that the requested item was a 
necessity for the enrollee's care. The Plan denied your request. The Plan says rules for payment have not been 
met. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for an automatic external defibrillator was not filed until June 29, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for an automatic external defibrillator (K0606) 
provided on May 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the non-emergency ambulance 
transportation (A0428) and ground mileage (A0425) provided on April 26, 2022. 
 
You asked the Plan to waive the copayment for the non-emergency ambulance transportation and ground 
mileage. You say that you were more than willing to drive the enrollee for free, but were told the insurance 
company said that they needed to be transported by ambulance. You also say that you believe you should not 
have to pay, and this service needs to be covered by the enrollee's insurance. The Plan denied your request. The 
Plan says this cost sharing was charged 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $295 copay per one-way trip for domestic ambulance services.  
 The enrollee has been asked to pay a $295 copay per one-way trip for the non-emergency ambulance 
transportation and ground mileage. This item/service falls within the Ambulance services benefit category. This 
means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost 
sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided 
that the Plan does not have to waive the copayment for the non-emergency ambulance transportation (A0428) 
and ground mileage (A0425) provided on April 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 8, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service July 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service October 17, 
2021. 
 
You asked the Plan to pay for procedure code 99053. You say that the services were medically necessary. The 
Plan denied your request. The Plan says procedure code 99053 is considered bundled and not separately 
payable. 
 
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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service October 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nail debridement (11721) provided on January 27, 2022, to 
June 21, 2022.  
 
You asked the Plan to pay for the nail debridement. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is non-covered. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
nail debridement have not been met. Therefore, we decided that the Plan does not have to pay for nail 
debridement (11721) provided on January 27, 2022, to June 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 31, 2022, billed with 
codes 81317, 81292, 81298, 81295, 81300, 81297, 81319 and 81294. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare billing regulations. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 31, 2022, billed with codes 81317, 81292, 81298, 81295, 81300, 81297, 81319 and 81294.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76377 & 99153 billed for date of service 
February 17, 2022. 
 You asked the Plan to pay for procedure codes 76377 & 99153. You say that the services were medically 
necessary. The Plan denied your request. The Plan says payment for code 76377 is bundled into payment for 
code 78201. Code 99153 is not eligible for separate payment. 
 
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 76377 
is a column II code to column I code 78201. This claim has not been billed with an appropriate modifier to 
bypass the edit. Code 99153 has a professional component / technical component indicator of 3. This service 
was billed in the hospital setting. 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 codes 76377 & 99153 billed for date of 
service February 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee arthroscopy. 
 
You asked the Plan to pre-approve knee arthroscopy. You say that you can't take any more injections and you 
have had knee pain for 20 years. The Plan denied your request. The Plan says knee arthroscopy is not medically 
necessary. The records do not show imaging demonstrating torn meniscus, and there is no record of physical 
therapy having been tried and failed. 
 
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 knee arthroscopy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you are being treated for pain in the right knee. You presented with medial right knee 
pain that you have had for several years. The knee pain is somewhat constant, feels like sharp, stabbing pain 
that is rated 3/10 in intensity on average with no radiation, numbness, or tingling. However, detailed 
documentation is not evident regarding a trial and failure of recent, reasonable, and comprehensive less 
invasive conservative care measures for the right knee. There is no indication that you have had physical 
therapy and/or trialed the brace that was recommended. Additionally, there is not diagnostic imaging corroborating the pathology in the right knee that could benefit from the requested procedure. There are limited 
large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical 
setting. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of knee arthroscopy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve knee arthroscopy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging with single-photon 
emission computed tomography (SPECT). 
 
You asked the Plan to pre-approve the imaging. You say that his is medically necessary. The Plan denied your 
request. The Plan says this request cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that SPECT 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 the imaging. Our reviewer says that the 
requested imaging is not medically reasonable or necessary. Our physician reviewer found that at issue is the 
medical appropriateness and necessity of carrying out a radionuclide stress test. The patient has atypical 
symptoms. The patients pre-test probability for an abnormal test is low and there is no documentation that the 
electrocardiogram (ECG) shows an uninterpretable pattern. There is no evidence provided that would support 
the need for radionuclide stress testing. In summary, there is insufficient documentation to support the medical 
necessity for the requested cardiac stress testing in this patients clinical management. 
 
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 imaging have not been met. Therefore, we decided that the Plan does not 
have to pre-approve myocardial perfusion imaging with single-photon emission computed tomography 
(SPECT).