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

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) scan for use with MRI 
TRUS fusion. 
 
You asked the Plan to pre-approve an MRI scan for use with MRI TRUS fusion. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI scan for use with MRI TRUS 
fusion. Our reviewer says that the services are medically necessary. Our physician reviewer found this enrollee 
has a significantly elevated prostate-specific antigen (PSA) and a normal physical exam. The fused MRI 
enables the urologist to identify a suspicious zone to do a targeted biopsy rather than the random core biopsy 
previously used in the past.  The standard of practice in urology is to use the fused MRI as a targeted approach. 
There is abundant research supporting this approach. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI scan for use with MRI TRUS fusion have been met. Therefore, we 
decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) scan for use with MRI TRUS 
fusion.  
 
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 pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. 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 inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary.  
 Our physician reviewer found based upon review the records provided, you do not meet the criteria for 
treatment in an acute inpatient mental health treatment beyond the date in question of April 6, 2022, forward 
and could have been treated in a lesser restrictive setting. You were not showing any suicidal or homicidal 
ideation, auditory or visual hallucinations and was not showing any aggressive behaviors. You were 
cooperative and compliant. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and 2 or more power seating system motors, expandable controller, and a harness. 
 
You asked the Plan to pre-approve an electronic connection between wheelchair controller and 2 or more 
power seating system motors, expandable controller, and a harness. 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 wheelchair accessories are covered when specific 
criteria are met. 
 
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 an electronic connection between 
wheelchair controller and 2 or more power seating system motors, expandable controller, and a harness. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the expandable 
controller (E2377), expandable controller harness (E2313), and electro connect (E2311) and other types of 
proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, 
etc.) are not medically necessary per Local Coverage Article: Wheelchair Options/Accessories - Policy Article 
(A52504). The enrollee does not require non-proportional input devices (e.g., sip and puff, head array, etc.). 
The enrollee does not require a separate display (i.e., for alternate control devices), other electronic devices 
(e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant 
control. The enrollee has 3 power options of tilt, recline, and power elevating leg rests but the enrollee does not 
need to control the power options through a joystick. The enrollee's upper extremity strength support that the 
enrollee can control any power options through their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection between wheelchair controller and 2 or more power 
seating system motors, expandable controller, and a harness have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an electronic connection between wheelchair controller and 2 or more power 
seating system motors, expandable controller, and a harness.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for compounded drugs (J7999-KD) provided on September 30, 2021. 
 
You asked the Plan to pay for compounded drugs. You say that this was billed correctly. The Plan denied your 
request. The Plan says that this service is incidental and not separately payable. 
 
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. The rules also say that when billing for compounded drugs, providers report 1 unit of code J7999 
with the KD modifier on a single claim line and enter the name and total dose of each drug of the refill in Box 
19 of the CMS 1500 or the appropriate comment loop of electronic claims.  
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The file shows that the compound drugs at issue were billed in accordance with 
Medicare rules and were not billed with any other services. The Plan has not provided any citation or 
explanation as to why the billed code is not payable. Therefore, we decided that the Plan has to pay for 
compounded drugs (J7999-KD) provided on September 30, 2021.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (93000) provided on 
September 14, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $30 
copayment for each Medicare-covered non-radiological diagnostic service.  
 
You have been asked to pay $12.41 for the Medicare-covered non-radiological diagnostic service provided.  
This is the Plans allowed amount for this service which is less than the applicable copayment. 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 electrocardiogram (93000) provided on 
September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment inpatient hospital observation (99236) 
provided on October 29, 2021. 
 
You asked the Plan to waive the copayment the inpatient hospital observation. You say that the services should 
be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing 
applied correctly based on the services provided. 
 
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 $30 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
 
  You have been asked to pay a $30 copayment for the inpatient hospital observation. Inpatient hospital 
observations fall 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 inpatient hospital observation (99236) provided on October 29, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transluminal ballon angioplasty provided to the enrollee on 
February 4, 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 code 37246 is "Transluminal balloon angioplasty (except 
lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or 
percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the 
angioplasty within the same artery; initial artery." 
 
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 balloon angioplasty of the 
perianastomotic segment is to be reported using CPT code 36902.  
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 transluminal ballon angioplasty provided to the enrollee on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) and the trigger point injection(s) 
(20552) rendered by the out-of-network (OON) provider on September 21, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit (99214) and the trigger point injection(s) (20552) rendered by the 
out-of-network (OON) provider on September 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided August 
16, 2021. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the pneumatic compression 
device was medically necessary. The Plan denied your request. The Plan says this device is non-covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676) provided August 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 home health skilled nursing visits. 
 
You asked the Plan to pre-approve 3 home health skilled nursing visits. 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 home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 3 home health skilled nursing visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the 
medical records provided there is no documentation that skilled nursing services are required to effectively 
provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. Provided records do not 
document any acute or unstable medical conditions or changes in medication or treatment which would 
necessitate any further skilled nursing visits beyond what have already been approved. No medical notes from 
the enrollees treating physician are provided documenting a need for additional skilled nursing 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 3 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 3 home health skilled nursing visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a ct scan provided on November 2, 2021. 
 
You asked the Plan to waive the copayment for the ct scan. You say that the services should be covered as you 
only received one scan. The Plan denied your request. The Plan says the cost-sharing applied correctly based 
on the services provided. The record indicates that there were 2separate scans performed. 
 
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 $200 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $200 copayment for a ct scan. CT scans 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 a ct scan provided on November 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve video monitoring of seizures for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical records do not support a trial of at least two seizure medications without 
success. 
 
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 the enrollee is said to have a history of seizures. He has reportedly been treated  with two anti-
convulsants. A request has been made for coverage of extended electroencephalogram (EEG) monitoring. 
However, the records which were provided for review did not otherwise demonstrate that the member had 
undergone a routine EEG in ths past. Such an evaluation would be the standard first line of evaluation for a 
seizure disorder. It is generally accepted that after initial EEG further diagnostic studies can be considered.  
 
 Given that there was no documentation of a routine EEG having been completed, it cannot be determined that 
the requested service would be the most appropriate level of service/care which could otherwise be provided to 
the enrollee at this time. 
 
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 video monitoring of seizures for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J1439). 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request does not meet the Plan's Part B step therapy criteria for the requested drug. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical 
records provided, the enrollee has not tried and failed the required drugs. There is no indication that these 
required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (J1439).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the unilateral breast ultrasound (76642) 
provided on November 23, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 each basic imaging service.  
 
You have been asked to pay a $10 copayment for the basic imaging service provided. 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 unilateral breast ultrasound (76642) 
provided on November 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) after 
April 9, 2022. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that SNF care remains medically 
reasonable and necessary. The Plan denied your request. The Plan says rules for SNF care have 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 the continuation of SNF care. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is an 82-
year-old woman with a history of heart disease, stroke, pulmonary fibrosis, hypertension, and peripheral 
vascular disease, who was admitted to the hospital on February 28, 2022, with acute diverticulitis with 
perforation. In this case, the enrollee no longer requires skilled nursing services. The enrollee does continue to 
require skilled therapy services; however, the documentation does not support that it is medically reasonable 
and necessary to provide skilled therapy services on a "daily basis" on an inpatient basis, in a skilled nursing 
facility setting. The requested services are no longer medically reasonable and 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 continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) after April 9, 2022.