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

 
We decided that the Plan does not have to pre-approve removal and replacement of the loop recorder. 
 
You asked the Plan to pre-approve removal and replacement of the loop recorder. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested services are 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 removal and replacement of the loop 
recorder. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found you have a history of an implantable loop recorder (ILR), 
now at end of battery life. You have a history of palpitations and dizziness. There have no significant 
arrhythmias detected since implantable loop recorder (ILR) implantation in 2019. There is no documentation 
provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for 
an ILR. In summary, there is insufficient documentation to support the medical necessity for insertion of an 
ILR in this your clinical management. Therefore, you do not meet criteria for the requested services. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of removal and replacement of the loop recorder have not been met. Therefore, we 
decided that the Plan does not have to pre-approve removal and replacement of the loop recorder.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx testing (0037U) provided on March 
24, 2022. 
 
You asked the Plan to pay for the FoundationOne CDx testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange.  
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the FoundationOne 
CDx testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
FoundationOne CDx testing (0037U) provided on March 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 7, 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 April 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upright walker. 
 
You asked the Plan to pre-approve an upright walker. You say that you have fallen using the walker you have. 
The Plan denied your request. The Plan says the medical records do not support this is necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a walker and related accessories are covered if 
the beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more 
mobility-related activities of daily living (MRADL) in the home and the beneficiary is able to safely use the 
walker. 
 We looked at the file and Medicare rules. The submitted medical records do not document whether you have a 
mobility limitation that significantly impairs your ability to participate in MRADLs. There is also no 
documentation showing that you are able to safely use a walker. Based on this information, we decided that 
Medicare rules for coverage of an upright walker have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an upright walker.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance transport rendered on August 10, 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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that providers report ambulance services under revenue 
code 540. 
 
We looked at the file and Medicare rules. The claim was not billed with the required 540 revenue code. Based 
on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the air ambulance transport rendered on August 
10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) 
(including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated 
technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or 
pharmacologic) and/or redistribution and/or rest reinjection (78452). 
 
You asked the Plan to pre-approve SPECT. You say that the enrollee needs to be seen at hospital for 
performing imaging. The Plan denied your request. The Plan says the request is not medically necessary 
because your records show you do not have high risk features of your chest pain and you have not yet had your 
approved heart stress test. We are unable to approve this request. 
 
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 SPECT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have clinical evidence of atherosclerosis but a normal ECG and chest x-ray. There are no 
signs of CHF. Nuclear medicine stress test has been approved, no results. NCD criteria for cardiac SPECT 
require an equivocal or non-diagnostic NM stress test or other clinical factors including inability to exercise 
etc. in order for SPECT imaging to be covered. The criteria have not 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 SPECT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative 
or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when 
performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest 
reinjection (78452).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 14, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was 
enrolled in hospice when the services were provided. 
 
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 ambulance services provided on May 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on July 3, 
2022. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says the delivery ticket is for 
the wrong date of service. 
 
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 proof of delivery. The submitted packing slip is for May 3, 2022, while the 
date of service on the claim is July 3, 2022. 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 the 
durable medical equipment (DME) provided on July 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99231) provided on July 17, 2022. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed is not separately payable. 
 
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 99231 is not supported in the medical record. Specifically, this service is included in the 
anesthesia service (01482) billed for the same date of service. Based on this information, we decided that 
Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99231) provided on July 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computerized dynamic posturography (CDP) (92548 
x12) and virtual reality advanced vestibular therapy (VIVE) (92700 x12). 
 
You asked the Plan to pre-approve the CDP and VIVE. The Plan denied your request. The Plan says this 
request for CDP and VIVE is considered experimental/investigational and not covered by the Plan. 
 
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 CDP and VIVE. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation that the computerized dynamic posturography (CDP) 
(92548 x12) and virtual reality advanced vestibular therapy (VIVE) (92700 x12) at issue in this case meet all 
Medicare criteria for medically reasonable and necessary for the enrollee. Our reviewer also found that a 
review of the current peer-reviewed medical literature and review of the provided medical records do not 
document that the requested services are standard of care for the enrollee's conditions with documented long 
term health benefits.  
 
 
 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 CDP and VIVE have not been met. Therefore, we decided that the Plan does 
not have to pre-approve computerized dynamic posturography (CDP) (92548 x12) and virtual reality advanced 
vestibular therapy (VIVE) (92700 x12).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wheelchair accessories provided on May 
25, 2022. 
 
You asked the Plan to waive the copayment for wheelchair accessories. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says this cost sharing was charged 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 20% 
coinsurance for durable medical equipment and related supplies. The allowed amounts of these wheelchair 
accessories total $450.67, resulting in a total coinsurance amount of $90.13. 
 
You have been asked to pay 20% coinsurance for wheelchair accessories. This item/service falls within the 
durable medical equipment and related supplies 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 wheelchair accessories provided on May 25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for colonoscopy services provided on June 14, 
2022. 
 
You asked the Plan to waive the copayment for colonoscopy services. You say that you are disputing the share 
cost. The Plan denied your request. The Plan says this cost sharing was charged 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 $325 
copayment for outpatient surgery.  
 
You have been asked to pay $325 copayment for colonoscopy services. This item/service falls within the 
outpatient surgery 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 colonoscopy services 
provided on June 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SelectMDx testing (81479) provided on February 23, 2022. 
 You asked the Plan to pay for SelectMDx testing. You say that this testing is necessary and covered by 
Medicare. The Plan denied your request. The Plan says this testing is not covered when done for screening 
purposes. 
 
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, SelectMDx testing, 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 
SelectMDx testing (81479) provided on February 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (27447) provided on June 1, 2022. 
 
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this provider is not eligible for separate payment. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners.  
 
 
 
  
Therefore, we decided that the Plan does not have to pay for surgical services (27447) provided on June 1, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee scooter (E0118) provided on July 22, 2022. 
 
You asked the Plan to pay for the knee scooter. You say that this item was medically necessary. The Plan 
denied your request. The Plan says the provider is not eligible for Medicare payment. 
 
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 a knee scooter (E0118) provided on July 
22, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional visits for revaluation of a physical therapy 
established plan of care (97164). 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary. 
The Plan denied your request. The Plan says you do not meet criteria for coverage of the requested services. 
 
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 these services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. 
Our physician reviewer found that according to Medicare a service is medically reasonable and necessary if it 
is safe and effective and not mainly for the convenience of the patient or the physician.  In order to be considered medically necessary a service cannot be investigational or experimental and must be 
ordered by qualified personnel and be appropriate to the patients medical needs and condition. Additionally, 
there must be an appropriate duration and frequency that is appropriate for the service. In this case, you have 
previously been treated with outpatient therapies and should be independent with a home exercise program. 
There is no documentation of a recent injury or decline in function. The additional therapy services requested 
are not an appropriate duration and frequency for treatment of your medical condition and therefore are not 
medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 10 additional visits for revaluation of a physical therapy established plan of care (97164).
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 the enrollee was admitted for respiratory failure and congestive heart failure. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that the enrollee 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot inserts. You say that you would like reconsideration because the 
requested foot inserts are medically necessary. The Plan denied your request. The Plan says the requested foot 
inserts are not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99204, 99214, 99244) with an oncologist 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits. You say that you have cancer, and you need to have surgery. 
You would like to see an OON provider for a second opinion. You want to be certain there arent any other 
options before having surgery performed. The Plan denied your request. The Plan says you must use network 
providers to get your medical care and services. A second opinion can be safely rendered by an in-network 
provider at the community level. 
 
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 
office visits (99204, 99214, 99244) with an oncologist to be provided by an out-of-network (OON) provider.