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

 
We decided that the Plan does not have to pre-approve a cardiology evaluation to be rendered by the out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested service. 
 
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 service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve a cardiology 
evaluation to be rendered by the out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a motorized scooter (K0800). 
 
You asked the Plan to pre-approve a motorized scooter. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 a motorized scooter (K0800). have 
been met. Medical records were not submitted in order to determine medical necessity of the requested item. 
Therefore, we decided that the Plan does not have to pre-approve a motorized scooter (K0800).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for dialysis services (90999) provided from 
November 1, 2021, to November 29, 2021. 
 
You asked the Plan to waive the copayment for the dialysis services. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the coinsurance applied 
correctly based on the services 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 a 20% 
coinsurance for Services to Treat Kidney Disease.  
 
 
  You have been asked to pay a 20% coinsurance for 13 dialysis service visits (total allowed is $3,822 x 20% = 
$764.4). Dialysis services fall within the Services to Treat Kidney Disease 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 dialysis services (90999) provided from November 1, 2021, to 
November 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says a trial of oral bisphosphonates is required before Prolia can be considered. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically necessary. Our physician reviewer found the record does not show a trial of the plan preferred 
drug or any reason it would be unsafe or ineffective 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve laparoscopic sleeve gastrectomy surgery (43775). 
 
You asked the Plan to pre-approve laparoscopic sleeve gastrectomy surgery. You say that this is medically 
reasonable and necessary. The Plan denied your request. The Plan says that the criteria for bariatric surgery 
have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare will cover bariatric surgery for enrollees 
who have:  
 
(1) a body mass index (BMI) of greater than or equal to 35;  
 
(2) at least one co-morbidity related to obesity; and 
 
(3) been unsuccessful with medical treatment for obesity.   
 
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 laparoscopic sleeve gastrectomy 
surgery. Our reviewer says that this surgery is medically reasonable and necessary. Our physician reviewer 
found this patient satisfied all criteria for bariatric surgery at this time. The patient has a BMI of greater than 35 
kg/m2, at least one co-morbid condition and failure at medical efforts with weight loss. The patient is an adult, 
with a BMI 42 kg/m2, has failed medical supervised weight loss and has sleep apnea and hypertension. The 
criteria for coverage of bariatric surgery have been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laparoscopic sleeve gastrectomy surgery have been met. Therefore, we decided 
that the Plan has to pre-approve laparoscopic sleeve gastrectomy surgery (43775).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan 
requires a trial of Infed and Venofer before it will approve Feraheme. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Feraheme. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Feraheme. Our physician reviewer 
found the enrollee has not tried and failed the Plan's preferred drugs of Infed and Venofer. The record does not 
show that these drugs would likely be less effective and/or have adverse effects 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 Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Feraheme.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
June 14, 2021, to June 28, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that two different hospitals 
are charging you $300 a day for the first 5 days. The Plan denied your request. The Plan says the copayment 
applied correctly. 
 
  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 $300 
copayment per day for days 1 to 5 for Medicare-covered inpatient hospital stays and a $0 copayment per day 
for additional days.  
 
You have been asked to pay a total of $1,500. ($300 x 5 days = $1,500). 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 the inpatient 
hospital stay provided from June 14, 2021, to June 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for medical supplies provided on March 8, 
2021. 
 
You asked the Plan to waive the coinsurance for medical supplies. You say that the nurse took the supplies 
with her on her last visit because you no longer needed the supplies. 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 20% 
coinsurance for in-network durable medical equipment supplies.  
 
The Plan confirmed the medical supplies were not returned. You have been asked to pay $18.60, which is 20% 
coinsurance of the allowed amount for medical supplies (code A6222) ($93 allowed amount x 20% coinsurance = $18.60). You have also been asked to pay $16.50, which is 20% coinsurance of the allowed amount for 
medical supplies (code A4216) ($82.50 allowed amount x 20% coinsurance = $16.50). You have been asked to 
pay a total of $35.10. Medical supplies fall within the Home Health Agency 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 coinsurance for medical supplies provided on March 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rolling walker with seat brand Nitro (E1399). 
 
You asked the Plan to pre-approve a rolling walker with seat brand Nitro. You say that the member is too tall 
for his current walker. The Plan denied your request. The Plan says they provided a walker with seat on July 
23, 2021, which is considered appropriate for the member's medical condition. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a rolling walker with seat. The members current walker serves the same purpose 
as a rolling walker with seat brand Nitro. Therefore, we decided that the Plan does not have to pre-approve a 
rolling walker with seat brand Nitro (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on 
November 30, 2021. 
 
You asked the Plan to pay for the special anesthesia service (99100). The Plan denied your request. The Plan 
says procedure code 76942 has been overturned and procedure code 99100 remains denied as bundled services 
are not eligible for separate payment.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on November 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that you would like the 
Plan to reconsider their denial. The Plan denied your request. The Plan says a power seat elevation feature 
(E2300) is not covered by Medicare or the Plan. 
 
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. Medicare specifically excludes coverage of power seat elevation systems coded as E2300. Therefore, we decided that the 
Plan does not have to pre-approve a power seat elevation feature (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a So Lite Scooter, to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a So Lite Scooter. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the documentation fails to indicate that you have a mobility limitation that 
significantly impairs your ability to participate in one or more mobility-related activities of daily living within 
your home. Additionally, your needs can be met by an in-network durable medical equipment provider. 
 
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 
a So Lite Scooter, to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve exercise equipment. 
 
You asked the Plan to pre-approve exercise equipment. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says exercise equipment is not covered by Medicare or the Plan. 
 
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 exercise equipment.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on January 26, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. While these services were billed by different providers, both providers have the same 
specialty/taxonomy code and are part of the same physician group. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the abdominal 
ultrasound (76705) provided on January 26, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic activities (97530) provided on November 18, 
2019. 
 You asked the Plan to pay for therapeutic activities. You say that these services were medically necessary and 
were billed correctly. The Plan denied your request. The Plan says these services are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 97530 is not supported in the medical record. Specifically, the documentation shows 
that this claim was billed by a physician. but the therapy services at issue were rendered by a Certified 
Occupational Therapy Assistant. There is no indication that the physician. was present on site while the therapy 
services were being rendered. The incident-to requirements have not been met in this case. Based on this 
information, we decided that Medicare rules for coverage of therapeutic activities have not been met. 
Therefore, we decided that the Plan does not have to pay for therapeutic activities (97530) provided on 
November 18, 2019.
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for the angiography (75716). We decided that the Plan does not have to 
pay for the aortography (75625).  
 
You asked the Plan to pay for the angiography (75716). You say that you would like reconsideration based on 
the records submitted. The Plan says that the documentation submitted does not support the services billed. 
 
We decided that the Plan has to pay for the angiography (75716).  
 
The Plan follows Medicare rules. Medicare rules say that Medicare plans must make reasonable and diligent 
efforts to gather and forward information to the Independent Review Entity (IRE).   
 
We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of the angiography (75716) have been met. Specifically, the Plan has denied this service 
stating that it is a column II code to column I code 37224. The Plan has not forwarded any evidence that CPT 
code 37224 has been billed by this provider. It is the burden of the Health Plan to substantiate their denial with 
evidence. In this case, the Plan's denial has not been substantiated. Therefore, we decided that the Plan has to 
pay for the angiography (75716).  
 
We also decided that the Plan does not have to pay for the aortography (75625). 
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly.  
 
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 aortography (75625). Our reviewer says 
that CPT code 75625 does not meet criteria for billing or reimbursement consideration. Our physician reviewer 
found the operative report does not include documentation of an abdominal aortography, and therefore cannot 
be verified.  
 
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 aortography (75625) have not been met. Therefore, we decided that the Plan 
does not have to pay for the aortography (75625). 
 
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: 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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
   
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cochlear battery services. 
 
You asked the Plan to pay for the cochlear battery services. You say that there are no suppliers in your area of 
the item in question. The Plan denied your request. The Plan says payment cannot be made to a provider not 
certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the cochlear battery services.