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

 
We decided that the Plan does not have to waive the cost-sharing for a Part B drug injection, imaging contrast 
supplies, cardiovascular stress testing, myocardial perfusion imaging, doppler extremity scan, and an office 
visit provided from November 29, 2021, to December 15, 2021. 
 You asked the Plan to waive the cost-sharing for Part B drug, imaging supplies, diagnostic tests, and office 
visit. You say that no one told you that you had to make any payments for these services. 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 Part B drug, 20% coinsurance for imaging supplies, $20 copayment for stress test, $110 
copayment for each diagnostic radiology test, and $30 copayment for specialist visit. The following is a 
summary of your cost-sharing amounts: 
 
Date of Service Service Provided 
Allowed 
Amount 
Cost-Share Per 
Contract 
Your Cost-
Share 
Responsibility 
November 29, 2021 Specialist Visit $109.01 $30 copayment $30 
December 8, 2021 
Myocardial 
Perfusion Imaging 
$318.53 $110 copayment $110 
December 8, 2021 Stress Test $60.24 $20 copayment $20 
December 8, 2021 Imaging Supplies $222.20 20% coinsurance $44.44 
December 8, 2021 Part B Drugs $238.20 20% coinsurance $47.64 
December 15, 2021 
Doppler Extremity 
Scan 
$126.18 $110 copayment $110 
Total    $362.08 
 
Therefore, your total cost-sharing amount is $362.08. 
 
You have been asked to pay 20% coinsurance for Part B drug, 20% coinsurance for imaging supplies, $20 
copayment for stress test, $110 copayment for each diagnostic radiology test, and $30 copayment for specialist 
visit. These items/services fall within the "Medicare Part B Prescription Drugs", "Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies", and "Physician/Practitioner Services, Including Doctor's Office Visits" 
benefit categories. 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 cost-sharing for a Part B drug injection, imaging 
contrast supplies, cardiovascular stress testing, myocardial perfusion imaging, doppler extremity scan, and an 
office visit provided from November 29, 2021, to December 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair replacement. 
 
You asked the Plan to pre-approve the replacement. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 replacement. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that another 
power device is not medically necessary. You have power wheelchair adequate for her needs and hves been 
deemed not safe based on assessment for a four wheeled scooter. 
 
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 replacement have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair replacement.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 25, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says medical records 
were not provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the lab services have been met. The 
submitted documentation does not contain medical records from the non-contract provider. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on April 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on June 7, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. 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 
(G0483) provided on June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for insertion of an IUD and levonorgestrel-releasing intrauterine 
contraceptive system (Mirena), 52 mg (6-year duration) provided on November 23, 2021. 
 
You asked the Plan to pay for insertion of an IUD and levonorgestrel-releasing intrauterine contraceptive 
system (Mirena). You say that the services was medically necessary. The Plan denied your request. The Plan 
says insertion of an IUD and levonorgestrel-releasing intrauterine contraceptive system (Mirena) does not 
meet the Medicare guidelines. 
 
The Plan follows Medicare rules. Medicare rules say that the patients medical record must clearly document 
the specific clinical circumstances supporting the medical necessity for services included within this Article. 
Evaluation to include abnormal uterine bleeding 
 
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 insertion of an IUD and levonorgestrel-
releasing intrauterine contraceptive system (Mirena). Our reviewer says that insertion of an IUD and 
levonorgestrel-releasing intrauterine contraceptive system (Mirena) is not medically necessary. Our physician 
reviewer found that the documentation does not support that you have abnormal uterine bleeding. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an IUD and levonorgestrel-releasing intrauterine contraceptive 
system (Mirena) have not been met. Therefore, we decided that the Plan does not have to pay for insertion of 
an intrauterine device (IUD) and levonorgestrel-releasing intrauterine contraceptive system (Mirena), 52 mg 
(6-year duration) provided on November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tumor treatment field therapy (TTFT) provided on June 
15, 2022. 
 
You asked the Plan to pay for TTFT. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says the enrollee did not meet criteria for the services rendered. 
 The Plan must follow Medicare rules. Medicare rules say that TTFT is covered for the treatment of newly 
diagnosed Glioblastoma Multiforme (GBM). 
 
We looked at the file and Medicare rules. Review of the file does not support that the enrollee was newly 
diagnosed with GBM. Based on this information, we decided that Medicare rules for coverage of TTFT have 
not been met. Therefore, we decided that the Plan does not have to pay for the tumor treatment field therapy 
(TTFT) provided on June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home therapy services (97530) provided on October 14, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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, the CPT Code Manual definition of code 97530 is "Therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes". 
 
We find that payment for CPT code 97530 is not supported in the medical record. Specifically, it is 
inappropriate to bill code 97530 for therapy services provided in the home setting. There is a more appropriate 
code to bill for these services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the home therapy 
services (97530) provided on October 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all 
components and accessories, custom fabricated. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says experimental and investigational procedures are not covered by Medicare. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at this time the requested robotic orthosis is not proven to be more beneficial for treatment of the 
patient's medical condition/function of hemiparesis after stroke than any available standard therapy such as 
conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, 
conventional muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable 
and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in 
widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single 
or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for podiatry services provided from February 
18, 2021, to April 7, 2022. 
 
You asked the Plan to waive the copayments for podiatry services. You say that this should be covered. The 
Plan denied your request. The Plan says the cost sharing will be applied according to the Plan contract. 
 
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 $40 
copayment for all other podiatry services per visit.  
 
You have been asked to pay $40 copayment for each podiatry service. This item/service falls within the 
Podiatry services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for podiatry services 
provided from February 18, 2021, to April 7, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the wheelchair rental provided on April 28, 2022. 
 
You asked the Plan to pay for the wheelchair rental. The Plan denied your request. The Plan says that the 
capped rental period (13 months) for this item has been exceeded. 
 
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. 
 
We looked at the file and Medicare rules. The Plan has not made reasonable and diligent efforts to gather and 
forward to us information regarding their decision to deny your request. In this case, the Plan has not shown 
that it has paid for 13 months of the requested wheelchair rental. Additionally, there is no evidence that the 
enrollee was going to purchase the wheelchair in question. As such, the Plan's denial cannot be substantiated. 
Therefore, we decided that the Plan has to pay for the wheelchair rental provided on April 28, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (22+ classes) provided on April 7, 2022. 
 
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the number of drug classes for which the enrollee was tested on this date is 
less than the number of drug classes billed. 
 
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, the CPT Code Manual definition of code G0483 is Drug Testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that 
22 or more drug classes were tested. Based on this information, we decided that Medicare rules for coverage of 
the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug 
testing (22+ classes) provided on April 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for amniotic fluid injections (code Q4206)- Fluid Flow or fluid 
GF, 1 cc and arthrocentesis, aspiration and/or injection (code 20610) provided on June 14, 2021 and 
June 21, 2021. 
 
You asked the Plan to pay for amniotic fluid injections-Fluid Flow or fluid GF, 1 cc and arthrocentesis, 
aspiration and/or injection. You say that amniotic fluid injections-Fluid Flow or fluid GF, 1 cc and 
arthrocentesis, aspiration and/or injection were medically necessary. The Plan denied your request. The Plan 
says amniotic fluid injections-Fluid Flow or fluid GF, 1 cc and arthrocentesis, aspiration and/or injection were 
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 pay for amniotic fluid injections-Fluid Flow or fluid 
GF, 1 cc and arthrocentesis, aspiration and/or injection. Our reviewer says that amniotic fluid injections-Fluid 
Flow or fluid GF, 1 cc and arthrocentesis, aspiration and/or injection are not considered medically reasonable 
and necessary. Our physician reviewer found that an amniotic fluid injection is experimental for joint pain. 
More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of amniotic fluid injections-Fluid Flow or fluid GF, 1 cc and arthrocentesis, 
aspiration and/or injection have not been met. Therefore, we decided that the Plan does not have to pay for 
amniotic fluid injections (code Q4206)- Fluid Flow or fluid GF, 1 cc and arthrocentesis, aspiration and/or 
injection (code 20610) provided on June 14, 2021 and June 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options. 
 
You asked the Plan to pre-approve Group 3 power wheelchair. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not have a qualifying diagnosis for a 
Group 3 power wheelchair. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
1. A neurological condition; 
2. Myopathy; or 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
Group 3 power wheelchair with multiple power options.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided there is no documentation that the enrollee 
requires the services on an inpatient basis, only in a skilled nursing facility setting. Based on the medical 
records provided the enrollee is not stable for discharge from the acute hospital. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tumor treatment field therapy (TTFT) services provided 
on May 15, 2022. 
 
You asked the Plan to pay for TTFT services. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the enrollee did not meet criteria for the services rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that TTFT is covered for enrollees who are newly 
diagnosed with supratentorial GBM. 
 
We looked at the file and Medicare rules. Review of the file does not support that the enrollee was newly 
diagnosed with GBM. Based on this information, we decided that Medicare rules for coverage of TTFT 
services have not been met. Therefore, we decided that the Plan does not have to pay for the tumor treatment 
field therapy (TTFT) services provided on May 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (22+ classes) provided to the enrollee on April 
7, 2022. 
 
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the number of drug classes for which the enrollee was tested on this date is 
less than the number of drug classes billed. 
 
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, the CPT Code Manual definition of code G0483 is Drug Testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that 
22 or more drug classes were tested. Based on this information, we decided that Medicare rules for coverage of 
the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing 
(22+ classes) provided to the enrollee on April 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebroplasty. 
 
You asked the Plan to pre-approve percutaneous vertebroplasty. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that PVA (Percutaneous Vertebroplasty (PVP) or 
Kyphoplasty (PKP)) is covered in patients that meet certain criteria. 
 
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 percutaneous vertebroplasty. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found sacroplasty for sacral 
insufficiency fractures remains experimental. More research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve percutaneous vertebroplasty.