Persius/hicric huggingface dataset:
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 is not medically 
necessary. 
 
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 the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program at least three hours a 
day and five days a week, or 15 hours over seven consecutive days. Currently, the enrollee requires minimal 
assistance with bed mobility and upper body dressing and moderate assistance with transfers. The enrollee has 
had a functional decline from his baseline level of function and will likely benefit from therapy but does not 
require the intensity of therapies provided on acute inpatient rehabilitation. 
 
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 Drive Medical ZooMe Auto-Flex electric scooter. 
 
You asked the Plan to pre-approve the electric scooter. You say that your current scooter is too heavy for you 
and would like to receive one less heavy. The Plan denied your request. The Plan says they approved an 
electric scooter for you on August 26, 2022, which serves the same function as the brand-specific scooter 
requested. 
 
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 electric scooter. Our physician 
reviewer found there is no documentation that the Drive Medical ZooMe Auto-Flex electric scooter at issue in 
this case meets all Medicare criteria for medically reasonable and necessary. Provided records do not document 
your electric scooter that was approved on August 26, 2022, has been lost, stolen, irreparably damaged or has 
reached its reasonable useful lifespan as required by Medicare rules. 
 
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 electric scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Drive Medical ZooMe Auto-Flex electric scooter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cologuard. 
 
You asked the Plan to pre-approve Cologuard. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you do not meet criteria for the requested services. 
 
The Plan must follow Medicare rules. Medicare rules say that Cologuard is covered for enrollees who are at 
average risk of developing colorectal cancer. 
 
We looked at the file and Medicare rules. Review of the file shows that you have chronic idiopathic 
constipation and a family history of colonic polyps. You had a positive Cologuard stool DNA test in April 
2021. You received a colonoscopy in June 2021 where a rectosigmoid colon polyp came back on pathology as 
a hyperplastic polyp. This means due to your polyp history, the requested testing is not a covered benefit. Based on this information, we decided that Medicare rules for coverage of Cologuard have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Cologuard.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure codes 88341, 88342, 88360, 
88381) provided to the enrollee on January 4, 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 the professional interpretation of a diagnostic test must be separately billed with modifier -26 by 
the interpreting physician. 
 
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 codes 88341, 88342, 88360, and 88381 are not supported in the medical record. Specifically, 
modifier 26 needs to be billed when there is a professional interpretation of a diagnostic test. 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 laboratory services (procedure codes 88341, 88342, 88360, 
88381) provided to the enrollee on January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
April 25, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service April 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Vabysmo. 
 
You asked the Plan to pre-approve Vabysmo. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for the requested drug have not been 
met. 
 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 Vabysmo. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of Avastin before they will approve the requested drug. The requested drug is a new 
start. The provided records do not indicate that the enrollee has tried and failed the Plan's preferred step-one 
alternative. The record does not indicate that the enrollee has a contraindication to, or would have an adverse 
effect from, the Plan's preferred step-one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Vabysmo.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99231) billed for dates of service 
February 7, 2022, to February 8, 2022. 
 
You asked the Plan to pay for subsequent hospital care. You say that this service is supported in the medical 
record and should be paid. The Plan denied your request. The Plan says the payment for this service is include 
in the global surgery package for code 44120, which was performed on February 2, 2022, and has a global 
surgery period of 90 days. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that the global surgery period 
for a surgical procedure includes payment for preoperative visits, intra-operative services, complications 
following surgery, postoperative visits, postsurgical pain management, supplies and miscellaneous services. 
 
We find that CPT code 99231 is not supported in the medical record. Specifically, these services are 
postoperative care provided by a physician of the same specialty (surgery) within the same physician 
group/practice. These services were provided within the global surgery period of code 44120, and were not 
billed with an appropriate modifier to indicate that they were not related to the initial surgical procedure. Based 
on this information, we decided that Medicare rules for coverage of subsequent hospital care have not been 
met. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99231) billed for 
dates of service February 7, 2022, to February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) and the infrared 
therapy (97026) provided on February 7, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services were rendered by an ineligible 
provider type. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were rendered 
by a licensed acupuncturist who was not under the supervision of a physician, physicians assistant, nurse 
practitioner, or clinical nurse specialist. Therefore, we decided that the Plan does not have to pay for the 
acupuncture treatment (97810, 97811) and the infrared therapy (97026) provided on February 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 15, 2021. 
 
You asked the Plan to pay for the genetic testing. The Plan denied your request. The Plan says this is not a 
covered screening test. 
 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 genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
genetic testing provided on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual physical exam provided on July 5, 2022. 
 
You asked the Plan to pay for an annual physical exam. The Plan denied your request. The Plan says the 
benefit was exhausted on May 19, 2022. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual physical exam provided on July 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service January 13, 
2022. 
 
You asked the Plan to pay for procedure code 99291. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 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 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service January 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
May 10, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100). 
 
You asked the Plan to pre-approve additional non-emergency transportation (A0100). You say that you have no 
other way to get to and from doctor appointments. You also say you had a heart attack in 2020 and have a heart 
monitor now. You also say you need to return to your provider. The Plan denied your request. The Plan says 
your Plan benefit allows for 10 one-way trips per plan year for routine non-emergency visits to Plan approved 
locations such as a doctor's appointments. The Plan also says that extra one-way transportation trips cannot be 
approved. 
 
  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 10 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve CT urogram. We decided that the Plan does not have to pre-
approve 3D rendering.  
 
You asked the Plan to pre-approve computed tomography (CT) urogram and 3D rendering. You say that you 
disagree with the Plan's denial. The Plan says that the requested services are not medically necessary. 
 We decided that the Plan has to pre-approve CT urogram.  
 
The Plan follows 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 CT urogram and 3D rendering. Our 
reviewer says that the documentation supports that the requested CT scan is medically reasonable and 
necessary. Our physician reviewer found the enrollee has a three-day episode of gross hematuria. Therefore, 
the enrollee meets criteria for the requested CT scan.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT urogram and 3D rendering. have been met. Therefore, we decided that the 
Plan has to pre-approve CT urogram.  
 
We also decided that the Plan does not have to pre-approve 3D rendering. 
 
The Plan follows 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 3D rendering. Our reviewer says that 
the documentation does not support that the 3D rendering is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a three-day episode of gross hematuria. The acquired images will easily be 
reconstructed into the sagittal and coronal planes per the standard protocol. No medical necessity of 3D 
rendering has been documented in the chart notes. Therefore, the enrollee does not meet criteria for the 3D 
rendering.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3D rendering have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 3D rendering. 
 
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 potassium self-testing monitoring device (E1399). 
 
You asked the Plan to pre-approve a potassium self-testing monitoring device. You say that you were admitted 
to the hospital with frequent hypokalemia, and you were able to self-monitor, you could prevent re-admissions. 
The Plan denied your request. The Plan says this is not medically necessary as there is no physician order and 
there is no criteria found for a home blood potassium meter as currently this device does not exist. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a potassium self-testing monitoring device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a potassium self-testing monitoring device (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says that the coverage 
criteria has 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 you continue to have a need for skilled therapy with ongoing safety concerns and 
a potential for functional improvement however, the documentation doesnt support that you would meet  
 criteria for admission to an acute inpatient rehabilitation facility. The physician reviewer says that you can 
receive further services at a lower level of care. 
 
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the hearing services. You say that the OON provider you are requesting to 
see is closer to your home than the in-network providers. You also say that the cost of the same hearing aids is 
more expensive at the in-network locations. The Plan denied your request. The Plan says your needs can be met 
within your health plan network, and you do not meet criteria for outside referral at this time. 
 
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 
hearing services to be provided by an out-of-network (OON) provider.