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

 
We decided that the Plan does not have to pre-approve a lumbar support pillow. 
 
You asked the Plan to pre-approve the pillow. You say that this will help relieve pain. The Plan denied your 
request. The Plan says this does not customarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a lumbar support pillow.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided from January 25, 2022, to 
March 25, 2022. 
 
You asked the Plan to pay for the telehealth visit. The Plan denied your request. The Plan says telehealth 
services are not covered out-of-network. 
 
The contract with the Plan covers Virtual Care (telehealth services). The Plan says telehealth services are not 
covered out-of-network. 
 
We looked at the file and the Plans rules. The file shows that the Plan does not cover telehealth services out-
of-network. Based on this information, we decided that Medicare rules for coverage of the telehealth visit have 
not been met. Therefore, we decided that the Plan does not have to pay for a telehealth visit provided from 
January 25, 2022, to March 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biopsy services provided to the enrollee on October 29, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 38525-RT (1 Unit) remains not supported. 
 
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 38525 is "Biopsy or excision of lymph node(s); open, 
deep axillary node(s)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the record indicates that the 
enrollee underwent sentinel node removal in the setting of breast cancer. The operative note describes the node 
as located immediately upon entry into the axilla beneath the subcutaneous tissue. This description is most 
consistent with a superficial node, not a deep axillary node. The elements of the coverage rules are not satisfied. 
 
We looked at this coder'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 pay for biopsy services provided to the enrollee on October 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage of 
the requested item have not been met. 
 
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 semi-electric hospital bed. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that, while the supplied documentation may support a fixed-height or even a variable-
height hospital bed, it does not support a semi-electric hospital bed. The documentation does not indicate that 
the enrollee has a frequent and immediate need for a change in body position to qualify for a semi-electric 
hospital bed. Furthermore, if the enrollee qualifies for a hospital bed, both the fixed-height and variable-height 
allow for elevation of the head and foot of bed with only the control mechanisms differing from the semi-
electric bed. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that it was the ordering physician's responsibility to 
obtain prior authorization. The Plan denied your request. The Plan says the services were provided out-of-
network and were not approved in advance. 
  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 lab services provided on February 28, 2022, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orthopedic pillow. 
 
You asked the Plan to pre-approve an orthopedic pillow. You say that the requested item is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that DME is defined as equipment which can 
withstand repeated use and be rented and used by successive patients.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an orthopedic pillow have not been met. Specifically, the requested item is not DME because it is 
not a reusable or rental-type item. Therefore, we decided that the Plan does not have to pre-approve an 
orthopedic pillow.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha SureClick. 
 
You asked the Plan to pre-approve Repatha. You say that Repatha is the most medically appropriate treatment 
for this enrollee. The Plan denied your request. The Plan says this drug is not eligible for coverage under the 
Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha SureClick.  
 
 Benefits for Repatha may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. 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 Medicare criteria for the requested CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
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 assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the 
blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trigger-point injections (20553) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve trigger-point injections. You say that the requested services are a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage for OON care have not been 
met. 
 
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 
trigger-point injections (20553) to be provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 21, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that this 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 March 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with accessories (K0849, 
E2361, E0973, E0973, E1028). 
 
You asked the Plan to pre-approve the group 3 power wheelchair with accessories. You say that the group 3 
power wheelchair is medically necessary. The Plan denied your request. The Plan says coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 power wheelchair with accessories (K0849, E2361, E0973, E0973, E1028).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on January 27, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be reported with the correct place 
of service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the outpatient place of 
service code, even though the enrollee was registered inpatient. Therefore, we decided that the Plan does not 
have to pay for anesthesia services provided to the enrollee on January 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from May 
23, 2021, to June 3, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITH MCC). 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 pay for the 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found that the documentation does not support a manifestation of systemic infection 
beyond tha tevidenced by SIRS criteria. Patient remained hemodynamically stable throughout admission with 
no documentation supporting a dysregulated host response to infection. The review has determined that the 
records did not support the use of A41.51 - sepsis due to Escherichia coli (E. coli) - in this case. The records 
supported DRG 690: KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from May 23, 2021, to June 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received from March 23, 2022, to 
March 24, 2022. 
 
You asked the Plan to pay for the drugs. You say that you should not be responsible for this. The Plan denied 
your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received 
from March 23, 2022, to March 24, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the cervical spine, 
(72141) 
 
You asked the Plan to pre-approve an MRI of the cervical spine. You say that the enrollee has worsening back 
pain and foot drop following surgery. The MRI is medically necessary. The Plan denied your request. The Plan 
says that the request for an MRI does not meet criteria. 
 
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 cervical spine. Our 
reviewer says that the service is medically necessary. Our physician reviewer found the enrollee has a history 
of foot drop from prior to lumbar spine surgery. She had previously undergone surgery without improvement in 
her foot drop. In such a setting/context, it is readily consistent with standards of care/practice to evaluate for 
other potential causative etiologies. Problems such as foot drop can localize to the cervical spine or brain. In 
such a setting it can be concluded that the requested study would otherwise be reasonable and necessary at this 
time. 
 
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 cervical spine have been met. Therefore, we decided that the Plan 
has to pre-approve a magnetic resonance imaging (MRI) of the cervical spine, (72141)  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of 
the lumbar spine (72148) provided on March 31, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $350 per 
day for other Medicare-covered diagnostic radiology services that are not ultrasounds.  
 
You have been asked to pay $240.65 for the Medicare-covered diagnostic radiology service provided. This is 
the Plans allowed amount for this service, which is less than the applicable copayment. 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 magnetic resonance imaging 
(MRI) of the lumbar spine (72148) provided on March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203), hot or cold packs therapy (97010), 
and the manual therapy techniques (97140) provided from February 21, 2022, through March 3, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under 
your contractual policy. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99203), hot or cold packs therapy (97010), and the 
manual therapy techniques (97140) provided from February 21, 2022, through March 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74181 billed for date of service March 12, 
2022. 
 
You asked the Plan to pay for procedure code 74181. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 74181 is bundled into payment for 
code 74183. 
 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 74181 
is a column II code to column I code 74183. 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 74181 billed for date of service March 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM sensor. You say that the requested item is a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage for CGMs and related 
supplies have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
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 assess 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 a Freestyle 
Libre CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM) sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90833) provided on March 
16, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient mental health services. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they were non-emergent and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90833) provided 
on March 16, 2022 by an out-of-network (OON) provider.