Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 3 power wheelchair with multiple power options. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the enrollee does not have a medical need for and cannot operate a group 3 
power wheelchair with the requested power options/features. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is 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 wheelchair. Our reviewer says that 
the requested wheelchair is medically reasonable or necessary. Our physician reviewer found that the clinical 
documentation shows that the enrollee would not be functionally appropriate for a cane or manual wheelchair. 
The enrollee has a qualifying diagnosis for a group 3 power wheelchair, with a past medical history of 
cerebrovascular accident, left hemiplegia, and functional impairments. The enrollee has an inability to self-
pressure relief with spasticity. Thus, the power options are also 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  
the wheelchair have been met. Therefore, we decided that the Plan has to pre-approve a group 3 power 
wheelchair with multiple power options.  
 
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 pay for inpatient hospital services provided to the enrollee from July 
18, 2021, to July 30, 2021. 
 
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 DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 438 (DISORDERS OF PANCREAS 
EXCEPT MALIGNANCY WITH MCC). 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 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found that while the provider documentation stated "ASPEN" criteria that include 
decreased oral intake, weight loss, and "moderate" muscle and fat losses, these are supported to be "moderate" 
in severity and were unclear related to severe malnutrition. It was also noted the patient refused the tube 
feeding prior to discharge and was able to meet calorie counts with a weight gain from 62.4 KG to 67.7 KG 
during the admission. The review has determined that the records did not support the use of E43 in this case. 
The records did not support the use of DRG 438 in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from July 18, 2021, to July 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on April 8, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you should only have to pay for the 
specialist copayment for that day, not an additional one for the x-ray. The Plan denied your request. The Plan 
says the copayment applied was correct. 
 
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 $10 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $10 copayment for an x-ray. An x-ray falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and 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 an x-ray provided on April 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Carboplatin, and Docetaxil. 
 
You asked the Plan to pre-approve Keytruda, Carboplatin, and Docetaxil. You say that the requested Keytruda, 
Carboplatin, and Docetaxil are medically necessary. The Plan denied your request. The Plan says the requested 
Keytruda, Carboplatin, and Docetaxil are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda, Carboplatin, and Docetaxil. 
Our reviewer says that the requested Keytruda, Carboplatin, and Docetaxil are not medically necessary. Our 
physician reviewer found the record indicates that the enrollee has a diagnosis of non-small cell 
adenocarcinoma of the lung, PDL-1 negative and without actionable mutations. The record indicates that the 
enrollee has had disease progression on Keytruda. The Food and Drug Administration has not stated that the 
requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not 
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria are 
not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda, Carboplatin, and Docetaxil have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Keytruda, Carboplatin, and Docetaxil.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SPRINT Percutaneous Electrical Nerve Stimulation 
(PENS) 
 
You asked the Plan to pre-approve PENS. 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 follows Medicare rules. Medicare rules say that PENS is only covered for certain indications. 
 
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 PENS. Our reviewer says that the 
documentation does not support that the requested services are medically necessary. Our physician reviewer 
found the enrollee has chronic right knee pain. The enrollee has tried physical therapy, over-the-counter 
medications, heat and a home exercise. The requested procedure is considered experimental/investigational for 
knee pain. Therefore, the enrollee does 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 PENS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve SPRINT Percutaneous Electrical Nerve Stimulation (PENS)
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service October 6, 
2021. 
 
You asked the Plan to pay for procedure code 93010. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 93010 is bundled into 
payment for codes 93355 and 33418. 
 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 93010 
is a column II code to column I codes 93355 and 33418. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 93010 billed for date of service 
October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care office visit provided on 
February 7, 2022. 
 
You asked the Plan to waive the copayment for a primary care office visit. You say that you were diagnosed 
with irritable bowel syndrome during the visit, but you did not know it would trigger an office visit copay. The 
Plan denied your request. The Plan says the copayment applied is correct. 
 
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 
copayment for a primary care physician's office visit. 
 
You have been asked to pay a $20 copayment for a primary care office visit. A primary care office visit falls 
within the Physician/Practitioner Services, Including Doctors Office Visits, 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 a primary care office visit provided on February 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cardiac catheterization provided on 
April 7, 2022. 
 
You asked the Plan to waive the copayment for the cardiac catheterization. You say that this should not be 
billed as a surgery and should have been billed as a basic radiological procedure. 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 a $365 
copayment for outpatient surgery services. 
 
You have been asked to pay a $365 copayment for outpatient surgery services for the cardiac catheterization. 
The cardiac catheterization falls within the Outpatient Hospital 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 copayment for the cardiac catheterization provided on April 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for additional time during a skilled nursing 
facility stay provided from January 1, 2022, to January 31, 2022. 
 
You asked the Plan to waive the copayment for a skilled nursing facility stay. You say that you had to stay 
longer due to COVID and feel you should not have to pay for these extra days. The Plan denied your request. 
The Plan says the copayment applied was correct. 
 
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 $188 
copayment per day for days 21-100 for skilled nursing facility (SNF) care. 11 days x $188 per day = $2,068. 
 
You have been asked to pay $2,068 copayment per day for days 21-100 for a skilled nursing facility stay. A 
skilled nursing facility stay falls within the Skilled Nursing Facility (SNF) 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 additional time during a skilled 
nursing facility stay provided from January 1, 2022, to January 31, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx test provided to the enrollee on August 10, 
2020. 
 
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says that the services did not meet the coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that Next Generation Sequencing is covered for either 
recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
The file says that the enrollee has metastatic prostate cancer. Next Generation Sequencing is covered for 
metastatic cancer as long as the test is Food and Drug Administration (FDA) approved. The FoundationOne 
CDx test is FDA approved. Based on this information, we decided that Medicare rules for coverage of the 
testing have been met. Therefore, we decided that the Plan has to pay for the FoundationOne CDx test provided 
to the enrollee on August 10, 2020.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diagnostic medial branch blocks. 
 
You asked the Plan to pre-approve diagnostic medial branch blocks. 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 follows Medicare rules. Medicare rules say that medial branch blocks are only covered for certain 
indications. 
 
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 diagnostic medial branch blocks. Our 
reviewer says that the documentation does not support that the requested services are medically reasonable or 
necessary. Our physician reviewer found the enrollee has chronic low back pain. A plain x-ray demonstrates 
spondylosis of the lower lumbar vertebra. There is no documentation of advanced imaging such as magnetic 
resonance imaging or computed tomography which would eliminate alternative pain generators. Therefore, the 
enrollee does 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 diagnostic medial branch blocks have not been met. Therefore, we decided that 
the Plan does not have to pre-approve diagnostic medial branch blocks.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 5, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 24, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A9279, S1015, and S8301 billed for date of 
service March 28, 2022. 
 
You asked the Plan to pay for procedure codes A9279, S1015, and S8301. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the billed codes are invalid 
for Medicare purposes.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes A9279, S1015, and S8301 have a Status Indicator of I on the Physician Fee 
Schedule. This means that procedure codes A9279, S1015, and S8301 are not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of procedure codes A9279, S1015, and 
S8301 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes A9279, 
S1015, and S8301 billed for date of service March 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs on May 02, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
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 Medicare Part B covered drugs at a primary care providers (PCP) office, specialists office or 
pharmacy. These drugs are covered under Part B of Original Medicare. Members of our plan receive coverage 
for these drugs through our plan. Covered drugs include drugs that usually aren't self-administered by the 
patient and are injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical 
center services. The provider billed in the amount of $1,548.58 and the Plan paid $1,238.86. $1,548.58 x 20% 
= $309.72. Therefore, results in the total cost sharing amount of $309.72. 
 
 
 You have been asked to pay a 20% coinsurance for Part B drugs. Part B drugs fall within the Medicare Part B 
prescription drugs 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 Part B drugs on 
May 02, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 20, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 20, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 8, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 8, 2022.