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

 
We decided that the Plan does not have to pre-approve electronic access connection accessory (E2310) and 
adjustable armrest (E0973). 
 
You asked the Plan to pre-approve the requested accessories for a power wheelchair. You say that these 
accessories are medically necessary. The Plan denied your request. The Plan says the criteria for coverage for 
these items have not been satisfied. 
 
The Plan follows Medicare rules. Medicare rules say that the equipment requested is subject to the criteria 
listed 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 the requested accessories for a power 
wheelchair. Our reviewer says that the requested electronic accessory is not medically reasonable and 
necessary. Our physician reviewer found you are a 58-year-old female with a medical history including right-
sided weakness resulting from a stroke who has been authorized for a group 3 power wheelchair with multiple 
power options. In this case, you have a neurologic disorder with functional deficits. Criteria for a power 
wheelchair are met. The requested electrical accessories are not medically necessary as you do have use of the 
upper extremity and can operate and control the power options using the switches that are included in the basic 
wheelchair. In addition, no separate payment is made for the adjustable armrest (E0973) requested as it is 
included in payment for the approved power tilt system. 
 
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 requested accessories for a power wheelchair have not been met. Therefore, 
we decided that the Plan does not have to pre-approve electronic access connection accessory (E2310) and 
adjustable armrest (E0973).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve BRCA1 and BRCA2 genetic testing (81162). 
 
You asked the Plan to pre-approve BRCA1 and BRCA2 genetic testing. You say that this is medically 
necessary. The Plan denied your request. The Plan says that the requirements for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that  BRCA1 and BRCA2 genetic testing is considered 
medically necessary for a beneficiary with a current diagnosis or a personal history of a cancer associated with 
the BRCA mutation who meets one or more of the criteria found in the most recent version of the National 
Comprehensive Cancer Network (NCCN) guidelines for Genetic/Familial High-Risk Assessment: Breast and 
Ovarian or other evidence based guideline addressing genetic testing, and the results will be used to benefit the 
individual tested in terms of potential to guide therapeutic decision making. 
 
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 BRCA1 and BRCA2 genetic testing. 
Our reviewer says that the criteria for coverage of the requested testing has been met. Our physician reviewer 
found the National Comprehensive Cancer Network (NCCN) Guidelines for Prostate Cancer state, "Germline 
testing should be considered in appropriate individuals where it is likely to impact the prostate cancer treatment 
and clinical trial options, management of risk of other cancers, and/or potential risk of cancer in family 
members." The documentation from the enrollee's urologist notes that this information can supplement clinical 
variables to predict disease progression and to inform personalized decisions on prostate cancer treatment such 
as pursuing active surveillance versus definitive treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of BRCA1 and BRCA2 genetic testing have been met. Therefore, we decided that 
the Plan has to pre-approve BRCA1 and BRCA2 genetic testing (81162).  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Skilled Nursing Facility (SNF) care. 
 
You asked the Plan to pre-approve the SNF care. You say that you would like reconsideration because the 
requested SNF care is medically necessary. The Plan denied your request. The Plan says you do not meet 
Medicare criteria for coverage. 
 
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 care. Our reviewer says that 
you do not require skilled nursing and/or skilled therapy services on a daily basis. Our physician reviewer 
found you do not have any parental medication; complex wound care or nutrition given via a feeding tube.  
You are medically stable without any acute exacerbation of chronic medical problems.  Your physical function 
is at or near your baseline and you can receive services at a lower 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Skilled Nursing Facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80307, G0480) provided on February 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says there was network providers available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for lab services (80307, G0480) provided on February 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that this ventilator is medically reasonable 
and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer says 
that this item is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 59-
year-old man with diagnoses that include Acute and chronic respiratory failure with hypercapnia, and Morbid 
(severe) obesity with alveolar hypoventilation. The enrollee is on chronic oxygen via nasal cannula. In this 
case, this patient does not have a neuromuscular disease, thoracic restrictive disease, or chronic respiratory 
failure consequent to chronic obstructive pulmonary disease. The enrollee does not meet the coverage criteria for a portable ventilator (E0466). 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from December 2, 2021, to December 
16, 2021. 
 
You asked the Plan to pay for home health services. You say that the enrollee was correctly assessed. The Plan 
denied your request. The Plan says that the records from November 1, 2021, contradict the submitted Outcome 
and Assessment Information Set (OASIS) data. 
 
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 has stated that the occupational therapy evaluation on November 1, 
2021, contradicts the submitted Outcome and Assessment Information Set (OASIS) data, but documentation of 
the occupational therapy evaluation on November 1, 2021, was not included in the medical records submitted 
in the case file. Without this information, the Plans denial cannot be verified. Therefore, we decided that the 
Plan has to pay for home health services provided from December 2, 2021, to December 16, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the rapid COVID-19 testing provided on 
June 5, 2021. 
 
You asked the Plan to provide reimbursement for the COVID-19 testing. You say that you believe that this 
testing should be covered due to the dangerous pandemic. The Plan denied your request. The Plan says this 
testing was not ordered by a physician and was not given due to signs/symptoms of COVID-19. You also 
agreed to have the test after being informed it could not be covered by insurance. 
 
The Plan must follow Medicare rules. Medicare rules say that services provided without relation to 
signs/symptoms of illness or injury are noncovered. The Plan contract indicates that only medically necessary 
COVID-19 testing ordered by a doctor is covered.   
 
We looked at the file and Medicare rules. You presented to the provider at issue and received a COVID test 
that was not ordered by a physician after an examination. You were told this was not to be covered by 
insurance. Based on this information, we decided that Medicare rules for coverage of the COVID-19 testing 
have not been met. Therefore, we decided that the Plan does not have to provide reimbursement for the rapid 
COVID-19 testing provided on June 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair and accessories. 
 
You asked the Plan to pre-approve a group 2 power wheelchair and accessories. You say that this is medically 
reasonable and necessary. The Plan denied your request. The Plan says there is not enough information to show 
that the member's mobility limitation cannot be resolved with a cane, walker, or 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 a group 2 power wheelchair and 
accessories. Our reviewer says that the requested group 2 power wheelchair is not medically reasonable and 
necessary. Our physician reviewer found the member is a 58-year-old male with a medical history including 
arthropathy of multiple joints with chronic back and hip pain who is requesting authorization for a power 
wheelchair. The documentation indicates he is able to ambulate household distances with an abnormal gait without an assistive device. In this case, the documentation does not support that the member's mobility deficit 
cannot be overcome with an alternative assistive device such as a walker, cane or manual 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 2 power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 2 power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided from February 2, 2022, through 
February 10, 2022. 
 
You asked the Plan to pay for acupuncture. You say that you visited an acupuncturist seeking relief for 
intolerable pain and the sessions have provided relief. You say that payment under insurance should be granted. 
The Plan denied your request. The Plan says a licensed acupuncturist is a non-covered provider type. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, an acupuncturist is a non-covered provider. 
Therefore, we decided that the Plan does not have to pay for acupuncture provided from February 2, 2022, 
through February 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 3D radiographic procedure (CPT code 76376) provided on 
February 18, 2022. 
 
You asked the Plan to pay for the 3D radiographic procedure. You say that the claim should be paid. The Plan 
denied your request. The Plan says the service is not covered 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. In this case, we have confirmed that code 76376 
is a column II code to column I code 71275 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 3D radiographic procedure (CPT code 76376) provided on February 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the neck 
rendered on January 12, 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. 
 
We looked at the file and Medicare rules. The file shows that only one reporting of the code is supported and 
was paid by the Plan. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance 
angiography (MRA) of the neck rendered on January 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 22, 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 August 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam (99203) provided on January 
27, 2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you would like the copayment 
waived because you were advised you would have no copay. You also say that this was a routine vision exam. 
The Plan denied your request. The Plan says you had a medical eye examination on January 27, 2022 due to 
having Pseudophakia and Keratoconjunctivitis sicca (dry eye). 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for Medicare-covered eye exams to diagnose and treat diseases and conditions of the eyes for 
Vision care.  
 
 
  You have been asked to pay a $40 copayment for Medicare-covered eye exams to diagnose and treat diseases 
and conditions of the eyes for the eye exam. The eye exam falls within the Vision care benefit category. The 
record shows that this was a medical eye exam. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the eye 
exam (99203) provided on January 27, 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 January 27, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 January 27, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home health aide (6 hours per week). 
 
You asked the Plan to pre-approve the services. You say that the enrollee needs additional care. The Plan 
denied your request. The Plan says homemaking services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home health aide is not medically reasonable or necessary. Our physician reviewer found the enrollee 
is medically stable without any recent hospitalizations or medical complications. The currently received 
homemaking services allow for appropriate support and care. The documentation does not support that the 
additional hours are needed to provide adequate support 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home health aide (6 hours per week).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a COVID-19 at-home test provided on January 17, 2022. 
 
You asked the Plan to pay for a COVID-19 at-home test. You say that you were under the impression that these 
kits were covered by Medicare and the Plan. The Plan denied your request. The Plan says rules for payment 
have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and a COVID-
19 at-home test is an OTC item. Therefore, we decided that the Plan does not have to pay for a COVID-19 at-
home test provided on January 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction procedure (92015) provided on February 1, 
2022. 
 
You asked the Plan to pay for an eye refraction. You say that these medically necessary refractive services are 
covered under your plan and were rendered by an in-network ophthalmologist. The Plan denied your request. 
The Plan says rules for payment have not been met.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services during a routine eye exam. 
 
We looked at the file and the Plan's rules. In this case, the service at issue was billed as a non-routine exam 
related to a diabetes diagnosis. Based on this information, we decided that the Plan's rules for coverage of an 
eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction 
procedure (92015) provided on February 1, 2022.