Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary The Plan denied your request. The Plan says the requested admission to a SNF is not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have any 
parental medication; complex wound care or nutrition given via a feeding tube. The enrollee is medically stable 
without any acute exacerbations of chronic medical problems. Although further rehabilitation services would 
be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a 
lower level of care than 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (CPT code K0800). 
 
You asked the Plan to pre-approve the DME. You say that you need this to be able to get around, to be outside 
anywhere or shopping. You state you really cannot walk at all and need this for mobility. The Plan denied your 
request. The Plan says the documentation submitted indicates that you have difficulty walking, but you are able 
to transfer and ambulate (walk) with the use of a wheeled walker in the home. 
 
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 DME. Our physician reviewer 
found the documentation indicates you are able to transfer and ambulate in the home with a wheeled walker. 
There is no indication that you require a powered scooter to assist with mobility-related self-care tasks 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 the DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve power operated vehicle, group 1 standard, patient weight capacity up to and including 300 
pounds (CPT code K0800).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on January 13, 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 procedure code 17003 is 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 CPT code. In this case, we have confirmed that code 17003 
is a column II code to column I code 17110. 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 the surgical services rendered on January 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided October 17, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that you did not use the ambulance. The Plan 
denied your request. The Plan says this service is not covered because you were not transported. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 17, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided October 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF system (CPT code(s): 33289 and 
C2624). 
 
You asked the Plan to pre-approve a CardioMEMS HF system. You say that the enrollee urgently needs this 
device and procedure due to their worsening heart failure. The Plan denied your request. The Plan says the 
CardioMEMS device at this point should only be approved for patients enrolled in a clinical trial. 
 
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 CardioMEMS HF system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found published expert opinion in the cardiology literature is supportive of the 
clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical 
studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. 
As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in this enrollees 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 a CardioMEMS HF system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF system (CPT code(s): 33289 and C2624).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for over-the-counter nicotine patches purchased on December 1, 2021. 
 
You asked the Plan to pay for nicotine patches. You say that it was your understanding that the Plan covered 
this item, and you would like the denial reviewed. The Plan denied your request. The Plan says that over-the-
counter items are not covered under the Wellness Wallet benefit. Therefore, this denial is appropriate. 
 
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. In addition, while Medicare does not cover OTC items, the Plan offers a supplemental benefit in 
excess of Medicare coverage. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan argues that OTC items are not covered by your Wellness 
Wallet benefit, but does not clarify the reason why this item is not being paid under your OTC benefit. There is 
no documentation to suggest that you specifically requested that this item be covered under the Wellness 
Wallet benefit and no other benefit. The Plan did not provide a copy of your original request with this file so 
that we could verify the location of purchase and item, but the Plan states that these are nicotine patches that 
were purchased from the pharmacy required by your benefit. The Plan also did not provide a copy of the OTC 
formulary. The Plan did not state or provide documentation to support that you have already used your $50 
OTC benefit for the quarter. The contract requires that qualifying purchases must be made in person at the 
specified pharmacy, by phone, or online. Therefore, we decided that the Plan has to pay for over-the-counter 
nicotine patches purchased on December 1, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prefabricated hip abduction orthosis (L1686) and addition to 
prefabricated hip abduction orthosis (L2624) provided January 24, 2022. 
 
You asked the Plan to pay for the orthoses. You say that please review the attached medical records. The Plan 
denied your request. The Plan says evidence of misrepresented services. 
 
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 physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. Specifically, the documentation submitted did not include a valid physician order. 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 
prefabricated hip abduction orthosis (L1686) and addition to prefabricated hip abduction orthosis (L2624) 
provided January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair and accessories. 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the enrollee does not have a qualifying diagnosis causing mobility limitation for which 
the power wheelchair is medically needed. 
 
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 DME. Our physician reviewer 
found the documentation does not reveal that the enrollee has a neurological condition, myopathy or congenital 
skeletal deformity causing the mobility limitations. The requested Group 3 power wheelchair K0858 and 
accessories are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the wheelchair and accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 diagnostic services provided September 20, 
2021. 
 
 
 You asked the Plan to pay for the laboratory services. You say that the information on your test order is 
sufficient to determine the Medicare medical necessity of the test order. The Plan denied your request. The Plan 
says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated 
to the members terminal condition. 
 
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 the Guardant360 diagnostic services provided September 20, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81206, 81235, 81321). 
 
You asked the Plan to pre-approve the genetic testing. You say that the services were 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 a panel constitutes a single procedural service, so 
one CPT code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were billed for a single panel. Based on 
this information, we decided that Medicare rules for coverage of the genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pre-approve genetic testing (81206, 81235, 81321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair (PWC), group 2 standard, captains 
chair, patient weight capacity up to and including 300 pounds (CPT code K0823). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says they do not see that you have mobility limitation that significantly impairs your ability 
to participate in one or more mobility-related activities of daily living (MRADLs) and no evidence supporting 
you being unable to self-propel a manual wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the 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 DME. Our physician reviewer found the documentation does not support that you require a PWC to accomplish mobility-related self-care 
tasks 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 the DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve power wheelchair (PWC), group 2 standard, captains chair, patient weight capacity up to and 
including 300 pounds (CPT code K0823).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 3, 2021. 
 
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 services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tangential biopsy of skin (11103) provided on August 17, 
2021. 
 
You asked the Plan to pay for tangential biopsy of skin. 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 coding regulations. 
 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 
tangential biopsy of skin is an add-on code and has not been billed with an appropriate primary procedure code. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for tangential biopsy of skin (11103) provided on August 17, 2021.
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 to get rehabilitation in an IRF. You say that 
you live alone and are not able to walk enough following a broken hip. You say that you need assistance 
getting dressed and getting to the toilet. The Plan denied your request. The Plan says the guidelines for 
coverage of IRF care have not been met. The Plan says that the care needed can be provided in a skilled 
nursing facility (SNF.) 
 
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 and does not need physical medicine and 
rehabilitation physician close 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 nursing needs identified or 
documented. At the current functional level, the enrollee needs skilled nursing facility (SNF) rehabilitation and 
does not require 3 hours a day five days a week of IRF therapies with interdisciplinary management. An 
uncomplicated hip fracture patient does not require an IRF admission. The complexity of the enrollee's medical 
and rehabilitation needs does not require an acute hospital inpatient rehabilitation stay with an interdisciplinary 
approach to rehabilitation care. Documentation does not support the medical necessity for admission to an IRF. 
The enrollee's rehabilitation needs can be provided in an alternate and low intensity setting such as in an SNF. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TENS device, four or more leads, for multiple nerve 
stimulation (CPT code E0730). 
 
You asked the Plan to pre-approve the TENS device. You say that the enrollee has lumbar spondylosis without 
myelopathy or radiculopathy. The Plan denied your request. The Plan says the TENS is not reasonable and 
necessary for the treatment of chronic low back pain. The Plan states the enrollee is not enrolled in a Medicare-
approved trial. 
 
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 the TENS device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the NCD, and LCD specifically exclude the use of a TENS unit for low back pain. 
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 the TENS device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve TENS device, four or more leads, for multiple nerve stimulation (CPT code E0730).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for eyeglasses provided on 
November 30, 2021. 
 
You asked the Plan to pay an additional amount for eyeglasses. The Plan denied your request. The Plan says 
you have already received the maximum amount of coverage allowed for this type of service. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
 We looked at the file and the Plan's rules. The file shows that you have received the maximum allowance for 
the eyewear benefit. Therefore, we decided that the Plan does not have to pay an additional amount for 
eyeglasses provided on November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an online digital assessment and management visit (98970) 
provided on December 22, 2021. 
 
You asked the Plan to pay for code 98970. You say that you were never seen by this provider, and you feel you 
should not be responsible for the amount billed. The Plan denied your request. The Plan says the provider did 
not provide evidence to show that a non-physician health care professional had a telehealth encounter with the 
enrollee, or that the enrollee was an established patient. The Plan has referred the claim to their anti-fraud 
committee for further analysis. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an online digital assessment and 
management visit (98970) provided on December 22, 2021, has been met. Therefore, we decided that the Plan 
does not have to pay for an online digital assessment and management visit (98970) provided on December 22, 
2021.  
 
Our decision only means that the Plan does not have to pay for this service and does not mean you are 
responsible for the charges. If you continue to be billed for services that did not take place, you may wish to 
report this to the CMS Regional Office.