Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies and materials (99072) provided on 
September 28, 2021. 
 
You asked the Plan to pay for the additional supplies and materials (99072). You say that you are submitting 
medical records and the claim should be reprocessed accordingly. The Plan denied your request. The Plan says 
CPT codes 99213, G0439, G0442, G0444, and G0447 have been paid. The Plan also says that CPT code 99072 
remains denied as bundled services are not eligible for separate payment. 
 
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 99072 is additional supplies, materials, and clinical staff 
time over and above those usually included in an office visit or other non-facility service(s), when performed 
during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease. 
 
We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status 
indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the additional supplies and materials (99072) 
have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and 
materials (99072) provided on September 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller 
(E2377) and harness (E2313). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the wheelchair accessories. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the member can control the power options using the switches that are included in the 
basic wheelchair. 
 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 accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an electronic connection (E2311), expandable controller (E2377) and 
harness (E2313).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Udenyca. 
 
You asked the Plan to pre-approve Udenyca. You say that the enrollee has had successful management with 
Udenyca. You also say that you feel it is medically necessary for the enrollee to continue this treatment. The 
Plan denied your request. The Plan says Udenyca is not being prescribed for a medically accepted indication. 
The Plan also says that no evidence of chemotherapy or transplant is found, and no literature or compendia 
support is found for this scenario. 
 
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 Udenyca. Our reviewer says that 
Udenyca is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Food 
and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. Our 
reviewer found that the Medicare approved drug compendia do not contain a supportive citation for the use of 
the requested drug in the enrollee's clinical situation. Our physician reviewer also found that 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 Udenyca have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Udenyca.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chiropractic manipulative treatment 
provided from January 7, 2021, through September 22, 2021. 
 
You asked the Plan to waive the copayment for the chiropractic manipulative treatments. You say that you 
were not aware that you were responsible for these charges until you submitted for reimbursement and was 
denied. You say that the wallet benefit clearly states it is to relieve pain for Nueromuscular Skeletal Disorders 
and you have been diagnosed with degenerative disk disease. The Plan denied your request. The Plan says the 
copayments applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for each Medicare-covered chiropractic visit.  
  You have been asked to pay a $20 copayment for each chiropractic treatment. ($20/treatment x 24 treatments = 
$480). The chiropractic manipulative treatments fall within the "Chiropractic 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 chiropractic manipulative treatment provided from 
January 7, 2021, through September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intravenous tubing extension set (S1015) and unspecified 
infection control supplies (S8301) provided on September 17, 2021. 
 
You asked the Plan to pay for an intravenous tubing extension set and unspecified infection control supplies. 
You say that the supplies at issue were a medical necessity for the enrollee. The Plan denied your request. The 
Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Codes S1015 and S8301 have a status indicator of I on the Physician Fee Schedule. This means that they are 
invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for 
coverage of an intravenous tubing extension set and unspecified infection control supplies have not been met. Therefore, we decided that the Plan does not have to pay for an intravenous tubing extension set (S1015) and 
unspecified infection control supplies (S8301) provided on September 17, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the locking mechanism (L5671) provided on October 11, 2021. 
 
You asked the Plan to pay for the locking mechanism. You say that you would like reconsideration because this 
is an imperative component of the prosthetic system. The Plan denied your request. The Plan says that this 
exceeds the MUE. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code L5671 is 2. The MAI value for this code is 2. You billed 2 units of this 
code, meeting the MUE. Based on this information, we decided that Medicare rules for coverage of the locking 
mechanism have been met. Of note, the Plan has not forwarded any additional evidence to support their denial. 
It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has 
not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the 
locking mechanism (L5671) provided on October 11, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided on 
December 6, 2021. 
 
You asked the Plan to pay for the comprehensive exam. You say that it was necessary for you to have this 
evaluation/second opinion performed by an oral surgeon. The Plan denied your request. The Plan says this 
service is covered once every three plan years. You had a previous comprehensive oral exam on November 15, 
2021, which was covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan can cover one 
comprehensive oral exam (D0150) every three plan years. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the comprehensive exam is requested 
in a frequency that is not covered under this benefit. Therefore, we decided that the Plan does not have to pay 
for the comprehensive oral exam (D0150) provided on December 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Keytruda. 
 
You asked the Plan to pre-approve the Keytruda. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says the drug is 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 the Keytruda. Our reviewer says that 
the drug is not medically necessary. Our physician reviewer found the drug is not FDA approved for the 
member's diagnosis and its use is not supported by one of the major drug compendia. 
 
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 Keytruda have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Keytruda.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the positron emission tomography (PET) 
scan of the whole body provided on January 15, 2021, billed with code 78813. 
 
You asked the Plan to pay for the PET scan interpretation. You say that the records support payment of both 
claims. The Plan denied your request. The Plan says code 78813 has an absolute MUE of 1 unit per day. This 
means that more than one unit cannot be paid in any situation. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 78813 is 1 unit. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the PET 
scan interpretation have not been met. Therefore, we decided that the Plan does not have to pay for the 
interpretation of the positron emission tomography (PET) scan of the whole body provided on January 15, 
2021, billed with code 78813.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met 
because the requested procedure is experimental/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 a Vertiflex procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Vertiflex device is experimental. More research is needed to demonstrate the 
safety and efficacy of the requested procedure. 
 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
(A0998) provided on November 2, 2021. 
 
You asked the Plan to pay for ambulance response without transport. You say that these services were 
medically necessary, and you did not need to be transported to the hospital because you recovered at the scene. 
The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit. When no 
transport is provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
 
 
 
 
 The ambulance company did not provide transport services on November 2, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without 
transport (A0998) provided on November 2, 2021.
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's needs cannot be accomplished at a 
lower level of care. The Plan denied your request. The Plan says the enrollee does not require an intensive 
interdisciplinary approach to rehab. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for osteomyelitis.  The complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment 
by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy 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: 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 rehab was recommended by the hospital doctor. The 
Plan denied your request. The Plan says you do not require an intensive multidisciplinary approach to daily 
therapy. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital for encephalopathy. Your medical problems are stable. You 
do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 15, 
2021. 
 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 October 15, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wavesense presto test strips. 
 
You asked the Plan to pre-approve the wavesense presto test strips. You say that the items are medically 
necessary. The Plan denied your request. The Plan says these are not the Plan's preferred drugs. 
 The Plan follows Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment 
(DME) to only those preferred brands and manufacturers. 
 
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 wavesense presto test strips. Our 
reviewer says that the member does need this item. Our physician reviewer found there is no indication of why 
the patient could not use the plan's preferred brand instead   of the meter he uses now.  Furthermore, there is no 
evidence from the office notes that the patient is taking insulin. 
 
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 wavesense presto test strips have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the wavesense presto test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medications. 
 
You asked the Plan to pre-approve the medications. You say that the medication being requested is medically 
reasonable and necessary for the enrollee to receive chemotherapy. The Plan denied your request. The Plan 
says the items in dispute are not covered in this scenario. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve medications as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve medications.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular risk assessment testing (81291 and 81479) 
provided on August 17, 2020. 
 
You asked the Plan to pay for the cardiovascular risk assessment testing. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare Part B 
covers cardiovascular disease screening tests when ordered by the physician who is treating the beneficiary for 
the purpose of early detection of cardiovascular disease in individuals without apparent signs or symptoms of 
cardiovascular disease. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the cardiovascular risk assessment testing, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Additionally, the documentation 
indicates that this testing was not ordered by the enrollee's treating physician and that the results will not 
impact the enrollee's treatment. Therefore, we decided that the Plan does not have to pay for the cardiovascular 
risk assessment testing (81291 and 81479) provided on August 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
22, 2021. 
 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 December 22, 
2021.