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

 
We decided that the Plan does not have to pre-approve the Group 3 power wheelchair (PWC) with multiple 
power options (coded K0861) with a power tilt and recline seating system. 
 
 
 You asked the Plan to pre-approve the Group 3 PWC with multiple power options. You say that this should be 
approved since the enrollee is at high risk of skin breakdown and pressure ulcers and requires this type of 
PWC. The Plan denied your request. The Plan says the PWC described by code K0861 cannot be covered as 
the criteria for power tilt/recline systems are not met. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with multiple power options can only 
be covered when the enrollee requires a mounted ventilator or meets the criteria for a power tilt/recline seating 
system. The criteria for this are listed 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 the Group 3 PWC with multiple power 
options. Our reviewer says that the documentation does not support the need for the requested PWC base with 
multiple power options. Our physician reviewer found there is insufficient documentation that the enrollee is at 
high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or utilizes 
intermittent catheterization for bladder management and is unable to independently transfer from the 
wheelchair to bed; or that a power seating system is needed to manage increased tone or spasticity. There is 
also no need for a ventilator to be mounted on the PWC. 
 
We looked at this physician's review, the file, and Medicare rules. As the PWC base code is not covered, the 
additional requested accessories are also not covered. Based on this information, we decided that Medicare 
rules for coverage of the Group 3 PWC with multiple power options have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Group 3 power wheelchair (PWC) with multiple power options 
(coded K0861) with a power tilt and recline seating system.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a positron emission tomography (PET) 
scan of the heart provided on September 23, 2021. 
 
You asked the Plan to waive the copayment for a PET scan. You say that you were in a lot of pain during the 
scan. You also say that you asked for the PET scan to stop. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for diagnostic imaging.  
 
 The record shows you did receive the PET scan. You have been asked to pay a $225 copayment for a PET 
scan. A PET scan 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 a positron emission tomography (PET) scan of 
the heart provided on September 23, 2021.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a tangential biopsy of skin (11102) 
rendered on September 30, 2021. 
 
You asked the Plan to waive the copayment for a tangential biopsy of skin. You say that you were at your 
dermatologist office for a mole scrape/biopsy, which took 10 to 15 minutes and there were no stitches. You 
also say the doctor applied a band-aid and after the procedure, the nurse came in, gave you the after visit papers 
and you left. You also say there was no observation. The Plan denied your request. The Plan says you were 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $260 
copayment for each Medicare-covered outpatient hospital facility visit.  
 You have been asked to pay $154, which is less than the $260 copayment for a tangential biopsy of skin. A 
tangential biopsy of skin falls within the outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers 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 tangential biopsy of skin (11102) rendered on September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the RomTech Adaptive Rehab Device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested equipment is not primarily medical in nature, and does not constitute 
medical equipment. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no indication that the device has been proven to be safe and effective and is not experimental or 
investigational. The device does not meet the requirements for coverage as detailed in Social Security Act, 
Section 1862(a)1(A). 
 
 
 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the RomTech Adaptive Rehab Device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
abdomen and pelvis provided on November 10, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you feel that the procedure was a 
screening and you should not be charged. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for each advanced imaging service, such as CT scans. 
 
 
 You have been asked to pay a $200 copayment for the CT scan. The CT scan 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 a computed tomography (CT) scan of the abdomen and pelvis provided on November 10, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided the Plan does not have to pay for imaging services provided to the enrollee on October 8, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit 
exists between 70496 and 70450. This PTP edit has a modifier indicator of 1, which indicates modifiers 
associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP 
code edit.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code and when necessary, the appropriate modifier.  
In this case, this claim cannot be paid as billed due to the omission of the required modifier. Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
imaging services provided to the enrollee on October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on January 7, 
2021 and billed under code 01360. 
 
You asked the Plan to pay for services provided to the enrollee. You say that this claim should be paid. The 
Plan denied your request. The Plan says while code 64447 was paid, the documentation submitted did not 
include documentation of an anesthesia report; therefore, the billed service cannot be verified. It is noted that 
multiple attempts were made to contact the provider for additional information. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. Insufficient records were provided to support the billing of code 01360. 
Therefore, we decided that the Plan does not have to pay for anesthesia services provided to the enrollee on 
January 7, 2021 and billed under code 01360.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the manual wheelchair. 
 
You asked the Plan to pre-approve the manual wheelchair. You say that you would like reconsideration 
because your condition makes it difficult for you to walk more than a block. The Plan denied your request. The 
Plan says you do not meet Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that manual wheelchairs may be covered if the 
beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more 
mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and 
bathing in customary locations in the home. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the manual wheelchair have not been met. Specifically, the documentation does not support that 
you have a mobility limitation which prevents you from doing one or more MRADLs. Therefore, we decided 
that the Plan does not have to pre-approve the manual wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF care. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not require an 
intensive, complex, 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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not require the intensity of services provided at an IRF. Specifically, the 
documentation does not show that you require fifteen hours per week of rehabilitative services and regular 
physician evaluation. Your needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on September 30, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the copayment is 
too high and you did not request the ambulance. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $440 
copayment for each one-way ground ambulance trip.  
 
 
 You have been asked to pay a $440 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance 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 
ambulance transportation services provided on September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extracorporeal photopheresis (36522) provided September 
22, 2021. 
 
You asked the Plan to pay for extracorporeal photopheresis. You say that the continuity of care for apheresis is 
in the best interest of the enrollee and supported by the letter of medical necessity from the physician. The Plan 
denied your request. The Plan says the available medical records do not support necessity of the treatment as 
defined by Medicare criteria. 
 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 pay for extracorporeal photopheresis. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found records report the extracorporeal photopheresis is requested for the treatment of 
bronchiolitis obliterans syndrome, however the records do not report a history of lung transplant status as 
required by the NCD for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of extracorporeal photopheresis have not been met. Therefore, we decided that the 
Plan does not have to pay for extracorporeal photopheresis (36522) provided September 22, 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that she 
would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the 
enrollee would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under 
the supervision of a physician with at least 3 visits weekly to regain or maintain her functional status. The 
enrollee can receive further services 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on November 
4, 2021. 
 
You asked the Plan to waive the copayment for laboratory services. You say that the laboratory services were 
part of your annual physical. The Plan denied your request. The Plan says the claims were processed correctly, 
and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $12 
copayment for laboratory services.  
 
You received laboratory services on November 4, 2021. Laboratory services are not included in annual 
wellness exams and are subject to separate cost-sharing charges. Therefore, you are responsible to pay the $12 
copayment.  
 
 You have been asked to pay a $12 copayment for laboratory services. Laboratory services 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 laboratory services provided on November 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, conventional air services, transport, one 
way (rotary wing) provided on May 1, 2021. 
 
You asked the Plan to pay for ambulance service, conventional air services, transport, one way (rotary wing). 
The Plan denied your request. The Plan says despite multiple outreached by the Plan, this provider has not 
submitted any clinical records to support the medical necessity of the services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment.   
  
We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents 
to justify payment of the claim. Therefore, we decided that the Plan does not have to pay for ambulance 
service, conventional air services, transport, one way (rotary wing) provided on May 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the epidural steroid injections. 
 
You asked the Plan to pre-approve the epidural steroid injections. You say that the service was denied but 
should be approved. The Plan denied your request. The Plan says the documentation does not clearly support 
any of the covered conditions therefore, the denial is upheld as not reasonable and 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 epidural steroid injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the member has chronic low back without radiculopathy or neurogenic 
claudication. Therefore, the LCD coverage criteria have not been met. 
 
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 epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the epidural steroid injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve platelet rich plasma injections. 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says there are currently no clinical indications for this technology. 
 
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 injections. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have right hip pain. The requested injections are experimental for hip pathology treatment. 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve platelet rich plasma injections.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has pain related to right 
knee osteoarthritis. He has not tried and failed the Plan's required drugs, Durolane, Monovisc, or Synvisc-One. 
The records do not show that the required drugs would be contraindicated or less effective; therefore, Gel-One 
is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gel-One.