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

 
We decided that the Plan does not have to pre-approve selective catheter placement, arterial system; initial third 
order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family (CPT 
code 36247), revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; 
with atherectomy, includes angioplasty within the same vessel, when performed (37225) and revascularization, 
endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), 
includes angioplasty within the same vessel, when performed (37221). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee's records do not show they have results of dye test showing significant 
narrowing or blockage of the enrollee's arteries to be treated or they have serious condition due to lack of blood 
flow (critical leg ischemia). The Plan states neither do they show the enrollee has tried and failed conservative 
treatment (maximal medical treatment and SET). 
 
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 physician reviewer 
found the documentation does not support the medical necessity of additional treatments. There has not been a 
reassessment since the enrollees angiographic procedure on which to support additional treatments. There is conflicting information in the medical record with portions documenting that the enrollee is denying leg pain or 
leg symptoms. There is also a lack of clarity in that there is documentation of plans for venous ablation in a 
patient that presumably is being treated for severe peripheral arterial disease (PAD). Therefore, unable to 
overturn the plan determination on the basis of medical necessity. 
 
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 selective catheter placement, arterial system; initial third order or more selective 
abdominal, pelvic, or lower extremity artery branch, within a vascular family (CPT code 36247), 
revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with 
atherectomy, includes angioplasty within the same vessel, when performed (37225) and revascularization, 
endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), 
includes angioplasty within the same vessel, when performed (37221).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance applied to an oxygen concentrator provided 
on January 18, 2022. We also decided that the Plan does not have to pay for the additional batteries for your 
oxygen concentrator that were provided on January 28, 2022. 
 
You asked the Plan to waive the coinsurance applied to the oxygen concentrator and to pay for the additional 
batteries. You say that you were told by the salesperson that your purchase was fully reimbursable through 
Medicare. The Plan denied your request. The Plan says the appropriate coinsurance was applied to the oxygen 
concentrator. The Plan says that coverage for the additional batteries is excluded from your benefits. 
 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 50% 
coinsurance of the Medicare-allowed amount for Medicare-covered durable medical equipment provided out-
of-network. The rules say Medicare covers durable medical equipment (DME) and related supplies only when 
it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, 
it is not considered reasonable and necessary. 
 
You have been asked to pay a 50% coinsurance of the Medicare-allowed amount for the oxygen concentrator. 
The provider who supplied you with the oxygen concentrator is out-of-network. The oxygen concentrator falls 
within the Medicare-covered durable medical equipment provided out-of-network benefit category. The total 
Medicare-allowed amount for this device was $1,158.90. You were asked to pay a $579.45 coinsurance, which 
is 50% of the total Medicare allowed amount for the oxygen concentrator. 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 applied to an oxygen concentrator provided on January 18, 2022.  
 
The file shows that you received a battery with the purchase of the oxygen concentrator. The additional 
batteries purchased serve the same purpose as the battery provided with the oxygen concentrator. While having 
back-up batteries may have been appropriate, neither Medicare nor the Plan covers or pays for these types of 
back-up items.  Therefore, we decided that the Plan does not have to pay for the additional batteries provided 
on January 28, 2022.
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. You say that you are requesting reconsideration stating an unfair 
decision was made on denial as the enrollee needs rehabilitation. The Plan denied your request. The Plan says 
based on Medicare guidelines the inpatient rehabilitation facility services you are requesting do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the enrollee was admitted for abdominal surgery, pneumonia, and a stroke. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the enrollee has a 
need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that this procedure fills a treatment gap for 
those patients that do not receive adequate relief from traditional conservative methods and do not have 
instability to indicate fusion is the appropriate treatment. You state the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says the enrollee's request is not 
medically necessary because there is little evidence in the medical literature to suggest that this is an 
appropriate procedure for their back pain. The Plan states it is not an accepted standard of medical practice for 
the diagnosis or treatment of back pain and it is considered experimental and investigational. 
 
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 intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. 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 the intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (CPT code 64628).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 the enrollee does not qualify for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs are custodial and can, as a practical matter, be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy visit provided on July 21, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for psychotherapy visit. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for psychotherapy visit provided on July 21, 2021, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits and routine ECGs provided on November 30, 
2021, to December 31, 2021, by an OON provider. 
 
You asked the Plan to pay for the office visits and routine ECGs. You say that these services should be covered 
because you had a heart attack and these were follow-up visits. The Plan denied your request. The Plan says 
there are in-network family practice providers available in your area. The out-of-network services were not 
authorized. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visits and routine ECGs provided on 
November 30, 2021, to December 31, 2021, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hereditary breast cancer-related disorders (e.g., 
hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); genomic sequence analysis 
panel, must include sequencing of at least 10 genes, always including BRCA1, BRCA2, CDH1, MLH1, MSH2, 
MSH6, PALB2, PTEN, STK11, and TP53 (81432) and Hereditary breast cancer-related disorders (e.g., 
hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); duplication/deletion 
analysis panel, must include analyses for BRCA1, BRCA2, MLH1, MSH2, and STK11 (81433). 
 
 
 You asked the Plan to pre-approve genetic testing. You say that you had the requested testing done in 2012 but 
the new test will include tests that were not available in 2012. The Plan denied your request. The Plan says no 
other cancers have been diagnosed. The documentation does not indicate that your providers are seeking 
treatment with chemotherapy and are requesting somatic testing for treatment options. You indicate that you 
are seeking additional genetic testing for personal and family future cancer risk. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA testing is limited to once-in-a-lifetime. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. The records show that you previously had the requested testing 
in 2012. Specifically, Medicare rules say that this testing is limited to once-in-a-lifetime. Therefore, we decided 
that the Plan does not have to pre-approve hereditary breast cancer-related disorders (e.g., hereditary breast 
cancer, hereditary ovarian cancer, hereditary endometrial cancer); genomic sequence analysis panel, must 
include sequencing of at least 10 genes, always including BRCA1, BRCA2, CDH1, MLH1, MSH2, MSH6, 
PALB2, PTEN, STK11, and TP53 (81432) and Hereditary breast cancer-related disorders (e.g., hereditary 
breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); duplication/deletion analysis panel, 
must include analyses for BRCA1, BRCA2, MLH1, MSH2, and STK11 (81433).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and related accessories. 
 
You asked the Plan to pre-approve a group 3 power wheelchair and related accessories. You say that this is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
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 and related accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction service (92015) provided on April 8, 2022. 
 You asked the Plan to pay for the vision service. You say that you advised the doctor should send the bill to 
your Vision Plan vendor. You also say that the office advised it was not their job. The Plan denied your 
request. The Plan says refraction services outside of a routine exam are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when performed as part of a routine exam by a Vision Plan provider. 
 
We looked at the file and the Plan's rules. Eye refractions during a routine exam are covered when performed 
by a Vision Plan provider. Based on this information, we decided that the Plan's rules for coverage of the vision 
service have not been met. The record shows that the refraction service was not performed with a routine exam. 
Therefore, we decided that the Plan does not have to pay for the refraction service (92015) provided on April 8, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower extremity prosthesis with microprocessor and 
addition. 
 
You asked the Plan to pre-approve these services. You say that the standard prosthesis you have is not fitting 
correctly. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a current prosthesis. The requested prosthesis serves the same purpose as the 
current equipment. Therefore, we decided that the Plan does not have to pre-approve a lower extremity 
prosthesis with microprocessor and addition.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
from February 27, 2022, to March 1, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you had an accident. You say that you 
found out you had 3 broken ribs. You say that you feel that you were inpatient during your time at the hospital. You say that The Plan denied your request. The Plan says self-administered drugs provided in an outpatient 
setting are not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided in an outpatient setting from February 27, 2022, to March 1, 2022.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair and related accessories. 
 
You asked the Plan to pre-approve the power wheelchair and related accessories. You say that this is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says this equipment is not 
covered for an enrollee in a SNF. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the power wheelchair and related accessories is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve the power wheelchair and related accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 1, 2022, billed with 
codes 81206, 81235, 81292, 81301, and 81321. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 1, 2022, billed with codes 81206, 81235, 81292, 81301, and 81321.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4220 billed for date of service February 23, 
2022. 
 
You asked the Plan to pay for procedure code A4220. The Plan denied your request. The Plan says procedure 
code A4220 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4220 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4220 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code A4220 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4220 billed for date of service February 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical record does not indicate that the enrollee requires services that they are 
not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 
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 the LTACH 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.