Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for CPT 75736. We decided that the Plan does not have to pay for CPT 
75716.  
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan says that the denied 
codes remain not supported. 
 
We decided that the Plan has to pay for CPT 75736.  
 
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 
CPT 75736 is "Angiography, pelvic, selective or supraselective, radiological supervision and interpretation." 
 
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 for CPT 75736. The medical documentation supports 
the use of procedure code CPT 75736-26-XU, with the description of the pelvic angiography, and due the 
Correct Coding Initiative (CCI) edit relationship between CPT 75736 and CPT 37244. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
CPT 75736.  
 
We also decided that the Plan does not have to pay for CPT 75716. 
 
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 
CPT 75716 is "Angiography, extremity, bilateral, radiological supervision and interpretation." 
 
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 for CPT 75716. Our reviewer found that the medical 
records do not indicate that an angiography, bilateral extremity was performed therefore, procedure code CPT 
75716 was not supported. Therefore, we decided that the Plan does not have to pay for CPT 75716. 
 
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 Pride Zero Turn 8 power scooter. 
 
You asked the Plan to pre-approve these services. You say that the enrollee would benefit from the power 
scooter. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a Pride Zero Turn 8 power scooter.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve a skilled nursing facility (SNF) admission. You say that you are appealing 
the denial of SNF. The Plan denied your request. The Plan says based on Medicare guidelines and the 
information we have about your condition you do not meet all the requirements. 
 
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 a skilled nursing facility (SNF) 
admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that 
the medical records do not document that you require services on an inpatient basis, only in a skilled nursing 
facility. You do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment 
of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. Our reviewer also found you do not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a skilled nursing facility (SNF) admission have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tracheostomy supplies to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the tracheostomy supplies. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
were non-emergent and prior authorization was not obtained. 
 
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 
Tracheostomy supplies to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an outpatient visit. You say that you prefer a second opinion from this out-
of-network physician. The Plan denied your request. The Plan says the service has been requested from an out-
of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an outpatient visit to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on March 16, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you were informed this service 
would be covered. 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 $55 
copayment for each Medicare covered standard x-ray and ultrasound.  
 
You have been asked to pay $55 copayment for an ultrasound. Ultrasounds fall 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 ultrasound provided on March 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skin seal protect moisturizer cloths. 
 
You asked the Plan to pre-approve these services. You say that the cloths help treat and prevent chronic 
intertrigo. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that skin sealants or barriers (A6250) are non-covered. 
 
We looked at the file and Medicare rules. The requested services are skin sealants described by code A6250. 
These services are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve 
skin seal protect moisturizer cloths.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not a covered benefit under the enrollees 
contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on February 16, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want your co-pay refunded. You 
thought you were on your way to some relief but all you got out of that visit was additional unnecessary pain 
and suffering. 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 
copayment for Specialists office visit. Covered services include: Consultation, diagnosis, and treatment by a 
specialist.  
 
You have been asked to pay a $20 copayment for office visit. Office visit falls within the Physician/Practitioner 
services, including doctor's 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 office visit on February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and can be provided in-network. 
 
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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement services provided to the enrollee on August 3, 
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 records do not support the services 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 the denied codes is: 
 
 
 CPT 11000: 
 
Debridement of extensive eczematous or infected skin; up to 10% of body surface 
 
CPT 15852: 
 
Dressing change (for other than burns) under anesthesia (other than local) 
 
We asked our coder 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 reviewer found that the procedure report documents 
that all procedures were performed on the left heel. In this case, these procedures would be inclusive to the 
primary procedure and not reported separately. 
 
We looked at this coder'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 pay for debridement services provided to the enrollee on August 3, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic testing provided on February 17, 
2022. 
 
You asked the Plan to waive the copayment for diagnostic testing. You say that you should only have a $30 
copayment. 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 $125 
copayment for Medicare covered radiological diagnostic services, not including x-rays, preformed in a 
physicians office or at a free-standing facility (such as radiology center or medical clinic).  
 
 
 
 
 You have been asked to pay $80.89 copayment which is less than the standard $125 copayment for diagnostic 
testing. Diagnostic testing 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 diagnostic testing provided on 
February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services provided to the enrollee on November 
21, 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 payment for this service is included in the fee for another procedure. 
 
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 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes."  
We asked our coder 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. Our reviewer found that medical records were not included for review. Therefore, 
the services cannot be verified. 
 
We looked at this coder'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 pay for critical care services provided to the enrollee on November 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic continuous glucose monitor (CGM), includes all 
supplies and accessories (K0553) therapeutic continuous glucose monitor receiver/monitor (K0554). 
 
You asked the Plan to pay for the CGM and supplies. You say that the enrollee has been having high blood 
sugars per the home health nurse. It would be safer for the enrollee to have the Freestyle Libre 2 during this 
time. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria and the 
request for the CGM cannot be approved as reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. 
Therefore, we decided that the Plan does not have to pay for therapeutic continuous glucose monitor (CGM), 
includes all supplies and accessories (K0553) therapeutic continuous glucose monitor receiver/monitor 
(K0554).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcatheter aortic valve replacement (TVAR) and 
related services provided from January 25, 2022, through January 26, 2022 
 
You asked the Plan to pay for the TVAR and related services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim is missing 
information required for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that it is mandatory to report a clinical trial number 
on claims for items/services provided in clinical trials/studies/registries, or under coverage with evidence 
development (CED). 
 
We looked at the file and Medicare rules. In this case, the services at issue were provided under a CED clinical 
trial. The claim at issue did not include the appropriate clinical trial number. Based on this information, we 
decided that Medicare rules for coverage of the TVAR and related services have not been met. Therefore, we 
decided that the Plan does not have to pay for the transcatheter aortic valve replacement (TVAR) and related 
services provided from January 25, 2022, through January 26, 2022
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 enrollee meets Medicare criteria for acute 
inpatient rehabilitation and will benefit from acute inpatient rehabilitation that cannot be accomplished at a 
lower level of care period. The Plan denied your request. The Plan says an intensive rehabilitation program 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 while the enrollee may benefit from continued physical and occupational therapy, the 
enrollee's rehabilitation needs can be safely provided in a lower intensity and alternate setting such as in a 
skilled nursing facility. There are no complex nursing or rehabilitation needs. While the enrollee has a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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 a group 1 standard, brand specific, power operated 
scooter (K0800). 
 
You asked the Plan to pre-approve a brand specific, power operated scooter. You say that you have submitted 
letters from your doctor regarding your disabilities and was still denied. You cannot get out of bed because you 
rely on your scooter. The Plan denied your request. The Plan says they contacted the office of your primary 
care physician to obtain an order for a power scooter that meets your needs as well as a face-to-face evaluation 
however, the Plan was unsuccessful. For a brand specific scooter, your physician must also document that the 
brands available through your Plan cannot meet your needs. However, the Plan was also not provided with this 
statement from your physician. The Victory LX sport is not a brand covered by the 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.  
 
The file shows that the Plan contacted the office of your primary care physician and documentation as well as a 
statement from your provider were not received. The records show that the requested Victory LX sport scooter 
is not a brand covered by the Plan. Please note, this brand has been discontinued and cannot be provided. This 
means that Medicare rules for coverage of a POV have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a group 1 standard, brand specific, power operated scooter (K0800).