Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing wound care services provided to the enrollee on March 
2, 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 that the place of service was incorrect. 
 
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. Place of Service (POS) 32 for Nursing Facility was used in this case. The rules 
state that POS 31 is used for covered nursing facility stays, and 32 is used for non-covered stays. The plan has 
not provided any documentation concerning the skilled nursing facility (SNF) stay during which this wound 
care was provided. The only skilled nursing code appearing in the case file, 99309, was denied in this case. 
With the evidence provided in the case file, POS 32 would appear to be correct. Therefore, we decided that the 
Plan has to pay for skilled nursing wound care services provided to the enrollee on March 2, 2022.  
 
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 pre-approve a power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that you need this scooter since you are 
unable to walk long distances. The Plan denied your request. The Plan says you walk with a cane, and you have 
some difficulty walking greater than 100 feet. The documentation also indicates that you only want the power 
scooter for use when you are outside your home. There is no documentation showing that you have attempted 
the use of a manual wheelchair or a properly fitted 
walker. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle, group 1 standard, patient weight capacity up to and including 
300 pounds (K0800).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest. 
 
You asked the Plan to pre-approve a CT scan of the chest. You say that a CT scan is needed for further 
treatment due to not being able to do surgery. You also say your provider believes you may have Emphysema 
or chronic obstructive pulmonary disease (COPD), and the scan is needed to confirm this. The Plan denied your 
request. The Plan says you are not experiencing a lung infection, nor do you have any abnormalities seen in 
other imaging testing. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the chest. Our reviewer 
says that a CT scan of the chest is not reasonable and necessary. Our physician reviewer found the enrollee has 
a diagnosis of COPD and is treated for the same, however, there is no record of a pulmonary function test or 
even a 2-view chest x-ray. The enrollee's physical exam of the lungs was normal and pulmonary consultation is 
planned. Our reviewer found the medical necessity of a CT of the chest has not yet been established in the 
submitted records. Our physician reviewer also found that the cardiac workup has been unremarkable, 
including echo. 
 
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 CT scan of the chest have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the chest.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy sessions. 
 
You asked the Plan to pre-approve physical therapy. You say that these services are medically necessary. The 
Plan denied your request. The Plan says the requested services have been correctly denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 physical therapy. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the enrollee's current needs do not require the services of a 
skilled physical therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 8 additional physical therapy sessions.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 23, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. 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, for 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 the lab 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 lab services provided on May 23, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Medihoney. 
 
You asked the Plan to pre-approve Medihoney. The Plan denied your request. The Plan says that Medihoney 
can be obtained over the counter. 
 
The Plan must follow Medicare rules. Medicare rules say that MA plans may cover health-related OTC items 
such as adhesive or elastic bandages, and OTC drugs such as antihistamines and analgesics, that meet the 
criteria as eligible supplemental benefits under Part C. 
 
We looked at the file and Medicare rules. The Plan offers a supplemental benefit for OTC items. The Evidence 
of Coverage says the enrollee has a $60 quarterly allowance to purchase OTC items with using their Plans 
Care Card. Based on this information, we decided that Medicare rules for coverage of Medihoney have been 
met. Therefore, we decided that the Plan has to pre-approve Medihoney.  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the chiropractic services provided on February 7, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that the services 
are excluded when performed by a chiropractor. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The services at issue were provided by a contract provider. The file does not show that the plan provided notice 
that the billed services would not be covered. Under Medicare rules, this means the billed services is 
considered approved by the plan. Therefore, we decided that the Plan has to pay for the chiropractic services 
provided on February 7, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve multiple vitamins, with or without minerals and trace 
elements, oral, per dose, not otherwise specified (A9153). 
 
You asked the Plan to pre-approve the vitamins. You say that the enrollee needs this. The Plan denied your 
request. The Plan says the requested service is not medically necessary. 
 
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 vitamins. Our reviewer says that the 
requested vitamins are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no specific clinical rationale for the requested vitamins and minerals and how they will treat the 
enrollee's underlying medical conditions. Therefore, the reviewer found that the requested service is 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 vitamins have not been met. Therefore, we decided that the Plan does not have to pre-approve multiple vitamins, with or without minerals and trace elements, oral, per dose, not 
otherwise specified (A9153).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) panel provided to the enrollee on December 15, 2021.
You asked the Plan to pay for the F1CDx panel. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that no Unique Test Identifier issued by Moldx is billed on the claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes, modifiers and in this case an identifier, based on the Medicare LCD guidelines applicable to the service. Medicare requires claims for this type of testing to be billed with a unique test identifier.
We looked at the file and Medicare rules. Based on L35025, this requirement is applicable as the claim shows the lab test was rendered. The LCD indicates all tests billed within this jurisdiction are required to be billed with a "Unique Test Identifier." We find do not find this identifier was billed on the claim. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) panel provided to the enrollee on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service June 8, 2022. 
 
You asked the Plan to pay for procedure code 70544. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 70544 is bundled into 
payment for code 70551. 
 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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service June 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VivAer procedure. 
 
You asked the Plan to pre-approve the VivAer procedure. You say that this procedure is medically necessary 
for your condition. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 VivAer procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you have listed diagnoses of nasal congestion, other specified disorders of nose 
and nasal sinuses, and hypertrophy of nasal turbinates. In this case, there is insufficient evidence in the medical 
literature to support that nasal laser surgery inside the nose is medically reasonable and necessary for the 
enrollee in this case. The long-term results of the proposed surgery, and how it compares to other treatment 
regimens has not been determined. 
 
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 VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the VivAer procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from a 
LTACH admission. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. 
 
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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (K0553, K0554) provided 
March 10, 2022. 
 
You asked the Plan to pay for the continuous glucose monitor. You say that the item was medically necessary. 
The Plan denied your request. The Plan says there was not a valid physician order for this equipment. 
 
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. Outreach by the plan determined the primary physician did 
not order this equipment. 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 a continuous 
glucose monitor (K0553, K0554) provided March 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra heavy-duty hospital bed with a weight capacity 
greater than 600 pounds (E0302). 
 
You asked the Plan to pre-approve an extra heavy-duty hospital bed. You say that your current bed is not 
strong enough for you, and you need a bed that can accommodate your weight. The Plan denied your request. 
The Plan says this request is not medically necessary because your records show you do not have a weight 
exceeding 600 pounds 
 
The Plan must follow Medicare rules. Medicare rules say that an extra heavy-duty hospital bed is covered if the 
beneficiary meets one of the criteria for a hospital bed and the beneficiary's weight exceeds 600 pounds.  
 
We looked at the file and Medicare rules. The record shows that do not have a weight exceeding 600 pounds. 
Based on this information, we decided that Medicare rules for coverage of an extra heavy-duty hospital bed 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an extra heavy-duty 
hospital bed with a weight capacity greater than 600 pounds (E0302).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a cardiac magnetic resonance imaging (MRI) for morphology and 
function (75561). 
 
You asked the Plan to pre-approve a cardiac MRI for morphology and function. You say that an MRI has been 
ordered to assess for infiltrative cardiac disease such as sarcoid that could cause their atrioventricular block. 
The Plan denied your request. The Plan says that prior test results do not show reason enough to perform the 
additional test requested. 
 
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 a cardiac MRI for morphology and 
function. Our reviewer says that a cardiac MRI for morphology and function is reasonable and necessary for 
the enrollee. Our physician reviewer found the enrollee has had extensive cardiac workup including 
catheterization and will need a pacemaker. The attending cardiologist has written an appeal explaining the 
unusual atrioventricular block considering the enrollee's age. Our reviewer also found that the requested cardiac 
MRI will provide valuable information if there is an infiltrative disorder and such evaluation must be done 
before a pacemaker is placed due to the MRI considerations after such placement. 
 
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 cardiac MRI for morphology and function have been met. Therefore, we 
decided that the Plan has to pre-approve a cardiac magnetic resonance imaging (MRI) for morphology and 
function (75561).  
 
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 pay for the laboratory services provided on March 31, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on March 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the spinal canal 
and contents (72148). 
 
You asked the Plan to pre-approve an MRI of the spinal canal and contents. You say that an MRI is needed to 
see if the enrollee is a candidate for possible injections. The Plan denied your request. The Plan says the 
guidelines have not been met because the clinical documentation does not show a failed trial of conservative 
treatment. 
 
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 spinal canal and 
contents. Our reviewer says that the medical necessity of the requested MRI of the lumbar spine has not been 
established in the provided records. Our physician reviewer found there has been no detailed neurological exam 
such as reflexes and motor strength. In other words, no red flag. Our reviewer found that the enrollee has not 
tried physical therapy. Our physician reviewer also found there was a plan for Medrol dose pack, but the 
records do not show such medication. 
 
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 spinal canal and contents have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the spinal canal and 
contents (72148).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a corneal hysteresis determination (92145) provided on June 
13, 2022. 
 
You asked the Plan to pay for a corneal hysteresis determination. You say that this member was seen twice on 
the dame day by different physicians. The Plan denied your request. The Plan says all corneal hysteresis 
assessments as a means of risk assessment or monitoring for progression of ophthalmic disease activity are 
non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT code 92145 is considered not medically 
necessary and will be automatically denied as a non-covered procedure.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a corneal hysteresis determination have not been met. Therefore, we decided that the Plan does not 
have to pay for a corneal hysteresis determination (92145) provided on June 13, 2022.