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

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator trial.  
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that the enrollee is in severe pain and 
needs to have surgery now. The Plan denied your request. The Plan says the requested procedure is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the implantation of a spinal cord stimulator is only 
covered as a last resort and when other treatment modalities, including surgical options, have been tried, did 
not prove satisfactory, or are judged to be unsuitable or a contraindication for 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 a spinal cord stimulator trial. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the records do not 
demonstrate that all treatment options have been tried for pain. Our physician reviewer found that surgery is an 
option now. Our physician reviewer found that the records do not demonstrate that surgery is unsuitable or a 
contraindication 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 a spinal cord stimulator trial have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal cord stimulator trial.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for your inpatient hospital stay provided on 
September 10, 2021 to September 12, 2021. 
 
You asked the Plan to waive the copayment for your inpatient hospital stay. You say that you were not given 
the choice for a semi-private or private room, so the copayment should be waived. The Plan denied your 
request. The Plan says the copayment amount charged is correct. 
 
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 $290 
copayment for inpatient hospital care per day, days 1-7.  
 
 
 You have been asked to pay a $580 copayment for two days of inpatient hospital care ($290x2=$580). An 
inpatient hospital stay falls within the Inpatient Hospital Care benefit category. 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 your inpatient hospital stay provided on September 10, 2021 to September 12, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Genesight Psychotropic panel provided on August 10, 
2021. 
 
You asked the Plan to pay for the Genesight Psychotropic panel. You say that this test is covered by the 
Medicare contractor for your state. You say that the Plan is violating Medicare rules in denying this testing. 
The Plan denied your request. The Plan says this testing is not supported as medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing must be ordered by the treating 
provider. While orders are not required to be signed, the physician must clearly document, in the medical 
record, his or her intent that the test be performed.  
 
In this case, the only record submitted is an unsigned order. No progress notes were submitted to document the 
intent that this testing be performed. As such, the Medicare rules for this panel have not been met. Therefore, 
we decided that the Plan does not have to pay for the Genesight Psychotropic panel provided on August 10, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (86077) provided on July 20, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE value has 
been exceeded. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 3 units of this 
code, exceeding the MUE. 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 the services (86077) 
provided on July 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 heavy duty power operated vehicle (K0801) 
and accessories. 
 
You asked the Plan to pre-approve a group 1 heavy duty power operated vehicle. You say that this item is 
medically reasonable and necessary for your condition. The Plan denied your request. The Plan says the criteria 
for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy-duty power operated vehicle is covered 
for beneficiaries weighing 285  450 pounds.  
 
We looked at the file and Medicare rules. In this case, the medical records indicate your weight is 160 pounds. 
Based on this weight, you do not meet the coverage criteria for the group 1 heavy duty power operated vehicle.  
Based on this information, we decided that Medicare rules for coverage of a group 1 heavy duty power 
operated vehicle have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 1 
heavy duty power operated vehicle (K0801) and accessories.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit (99348) provided on May 4, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the enrollees claim would be covered under 
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify 
the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the home visit (99348) provided on May 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation (A0427, A0425) provided on 
November 5, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that these services were billed according to 
Medicare regulations and should be paid. The Plan denied your request. The Plan says that the enrollee was in 
police custody at the time of services, and therefore this claim is missing a modifier and was not billed 
correctly to be a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the documentation shows that the enrollee was sitting in a police car when the ambulance arrived 
on scene and was in police custody at the time of services. The facility claim from the same date of service also 
corroborates that the enrollee was in police custody on this date. These services were not billed with the 
required QJ modifier which would indicate that the enrollee is in a jurisdiction where the necessary criteria are 
met, and Medicare payment may be made. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to 
pay for the ambulance transportation (A0427, A0425) provided on November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an echocardiography, transthoracic, real-time with image 
documentation (93306) provided on October 19, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an echocardiography, transthoracic, real-time with image documentation 
(93306). You say that the patient was seen at your office and the health condition of the patient required the 
doctor to do the procedure based on medical necessity. You also say that the patient was complaining of chest 
pain and chest tightness while at work. The Plan denied your request. The Plan says they determined that both 
the referring and attending providers are all non-participating with the Plan and the non-participating provider 
did not follow the Plan's rules to request authorization for out-of-network care. 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 provider at issue in this case is not a network provider with the Plan. 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 an echocardiography, transthoracic, real-time with image documentation 
(93306). Our reviewer says that this does not meet criteria. Our physician reviewer found there is inadequate 
supportive evidence for the medical necessity of this service in this patient's 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 an echocardiography, transthoracic, real-time with image documentation 
(93306) have not been met.  
 
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 pay for an echocardiography, transthoracic, real-time with image 
documentation (93306). Therefore, we decided that the Plan does not have to pay for an echocardiography, 
transthoracic, real-time with image documentation (93306) provided on October 19, 2020, by an out-of-
network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a physical therapy visit provided on 
October 20, 2021. 
 
You asked the Plan to waive the copayment for a physical therapy visit. You say that you had two physical 
therapy visits while in the hospital post-op. You also say that you should not have to pay for it since you were 
an inpatient. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 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 each in-network physical therapy visit. The Plan contract also says that there may be additional 
cost sharing for services other than outpatient surgery, including therapeutic services. 
 
The record shows you received physical therapy after having surgery. Those services may be charged at an 
additional cost. The record also shows that you were not an inpatient at the time. Although you had two 
physical therapy visits, you have only been asked to pay a $40 copayment for one physical therapy visit. A 
physical therapy visit falls within the Outpatient Rehabilitation Services benefit category. 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 a physical therapy visit provided on October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on November 29, 
2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that this was your annual wellness visit 
and you should not owe a copayment. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct amount. 
 
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 $5 
copayment for primary care provider visits. 
 
The medical records show that you received services beyond an annual wellness exam on November 29, 2021. 
Therefore, you are responsible to pay the $5 copayment.   You have been asked to pay a $5 copayment for an office visit. An office visit falls within the 
physician/practitioner services, including doctors office visits benefit category. 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 an office visit provided on November 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (E1002, E1028, K0858, 
E2363). 
 
You asked the Plan to pre-approve the group 3 power wheelchair. You say that this power wheelchair is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 group 3 power wheelchair. Our 
reviewer says that this chair is not medically necessary. Our physician reviewer found there is no 
documentation provided indicating that the enrollee can safely operate a power 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 the group 3 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 3 power wheelchair (E1002, E1028, K0858, E2363).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 appears to be improving and more stable but requires short-term 
additional acute care services that can be safely administered at the current facility to further stabilize. There 
are no services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. Transfer to a lower level of care may be considered when treatment is completed and the enrollee is 
more stable. 
 
 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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 7, 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 June 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walk-in tub, provided on July 19, 2021. 
 
You asked the Plan to pay for the walk-in tub. You say that the item should be covered. The Plan denied your 
request. The Plan says this is not a covered item. 
 
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 pay for the walk-in tub, provided on July 19, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test (U0004) and infectious agent detection 
by nucleic acid (U0005) provided on October 5, 2021. 
 
You asked the Plan to pay for the COVID-19 test and infectious agent detection. You say that you believe this 
claim was denied incorrectly. 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 enrollees 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 COVID-19 test (U0004) and infectious agent detection by 
nucleic acid (U0005) provided on October 5, 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 IRF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 that that the patient was admitted for coronary artery bypass grafting and ligation of 
left atrial appendage. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In 
conclusion, there is not a reasonable expectation that this patient will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99202) provided March 25, 2021. 
 
You asked the Plan to pay for the office visit. You say that kindly review the attached medical records and 
process the denied codes towards payment. The Plan denied your request. The Plan says there is evidence of 
misrepresented services. 
 
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 the outpatient office visit (99202) 
provided March 25, 2021. have been met. there is no evidence of an established relationship between the 
enrollee and the ordering physician. The records show that the Plan made multiple attempts to obtain medical 
records from the provider without success. Therefore, we decided that the Plan does not have to pay for the 
outpatient office visit (99202) provided March 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone 5 mg tablet. 
 
You asked the Plan to pre-approve Prednisone. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says this drug is not covered under the enrollee's medical 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 Prednisone 5 mg tablet.  
 
 
 
 Benefits for Prednisone may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.