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

 
We decided that the Plan does not have to pay for the seat lift (E0630), provided on November 9, 2021. 
 
You asked the Plan to pay for the seat lift. You say that the item is medically necessary. The Plan denied your 
request. The Plan says the records show that you are not confined to a bed and are able to perform adult daily 
living activities. Additionally, there is no record of an authorization or a signed written order prior to the 
delivery of the seat lift. 
 
The Plan must follow Medicare rules. Medicare rules say that a patient lift is covered if transfer between bed 
and a chair, wheelchair, or commode is required and, without the use of a lift, the beneficiary would be bed 
confined. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the seat lift have not been met. Therefore, we decided that the Plan does not have to pay for the 
seat lift (E0630), provided on November 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI). 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an ESI is 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documentation of a physical 
examination of the lumbar spine or the lower extremities or imaging of the lumbar spine. There is no 
documentation of previous injections being completed in the lumbar region. The enrollee does not meet the 
criteria for an ESI and the services are 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 a lumbar epidural steroid injection (ESI).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on November 
7, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The file shows that CPT code 70450 was billed with CPT code 70496. We find that CPT code 70450 may be 
eligible for payment when billed with this code pair. The claim information does not show that the code at 
issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare 
rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay 
for the computed tomography (CT) scan provided on November 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on July 12, 2021. 
 
You asked the Plan to pay for the testing services. You say that there has been a misinterpretation of the 
guidelines. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. The claim billed a place of service as 81, an independent laboratory. We looked at the file and the rules. If an 
independent lab bills for services, the place where the sample was taken is reported as the place of service. The 
records do not indicate the specimen was obtained at the independent laboratory. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the lab testing services provided on July 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 20, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an outpatient hospital setting and 
should have been billed with POS code 22. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on August 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 15, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on July 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a liquid nutritional supplement. 
 
You asked the Plan to pre-approve the supplement. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve a liquid nutritional supplement.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ER visit provided on April 19, 2021. 
 
You asked the Plan to pay for the ER visit. You say that the patient was seen in the emergency room twice on 
the same date of service. You say that modifier 25 was added and the claim should be reprocessed for payment. 
The Plan denied your request. The Plan says Medicare does not pay separately for services included within 
another service. 
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the ER visit provided on April 19, 
2021, have been met. Therefore, we decided that the Plan does not have to pay for the ER visit provided on 
April 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 4, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on November 14, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography 
angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with 
column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the 
head/brain rendered on November 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 28, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed an incorrect place of service on the claim. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that it is medically necessary for the enrollee to see 
an OON provider. The Plan denied your request. The Plan says there are in-network providers available to treat 
the enrollee's condition. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of a permanent cardiac contractility 
modulation (CCM) system (0408T). 
 
You asked the Plan to pre-approve cardiac contractility modulation system. You say that this is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is 
considered 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 cardiac contractility modulation system. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found at issue is whether implantation of the CCM system in this patient is 
medically necessary for the treatment of congestive heart failure which has been deemed refractory to optimal 
medical therapy. An exhaustive review of the current medical literature pertaining to the CCM system confirms 
multiple observational studies suggesting clinical benefit from CCM. Several randomized clinical trials of 
CCM versus control have also been reported, along with meta-analysis pooling the data from multiple studies, with CCM providing meaningful improvement in quality-of-life scores and objective functional capacity. 
While the clinical studies led to Food and Drug Administration approval in 2019, CCM remains the subject of 
multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to 
quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume 
clinical outcomes and benefit.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac contractility modulation system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the implantation of a permanent cardiac contractility 
modulation (CCM) system (0408T).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on December 
14, 2020. 
 
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The file shows that CPT code 70450 was billed with CPT code 70496. We find that CPT code 70450 may be 
eligible for payment when billed with this code pair. The claim information does not show that the code at 
issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare 
rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay 
for the computed tomography (CT) scan provided on December 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on October 6, 
2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The file shows that CPT code 70450 was billed with CPT code 70496. We find that CPT code 70450 may be 
eligible for payment when billed with this code pair. The claim does not show that the code at issue was billed 
with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage 
of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the 
computed tomography (CT) scan provided on October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 80307, 83789 and 
G0480) provided on September 24, 2021. 
 You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. CPT code(s): 80307, 
83789 and G0480, remain not supported. The place of service on the CMS-1500 form line 24B must reflect the 
location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory 
specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim 
history indicates that the specimen was obtained in a Psychiatric Residential Treatment Center POS 56. It is 
noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (CPT code(s): 80307, 83789 and G0480) provided 
on September 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care first 30-74 minutes (99291) provided on August 
11, 2021. 
 
You asked the Plan to pay for critical care. You say that these services were medically necessary and were 
billed appropriately. The Plan denied your request. The Plan says that the documentation for this encounter 
does not include information regarding the time spent performing this service. This code is a time-specific 
service and cannot be supported in the record without this information. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-
74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the submitted documentation 
does not show how long this service was performed on the date in question. Based on this information, we 
decided that Medicare rules for coverage of critical care have not been met. Therefore, we decided that the Plan 
does not have to pay for critical care first 30-74 minutes (99291) provided on August 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs to a sit to stand patient lift. 
 
You asked the Plan to pre-approve the repairs. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve repairs to a sit to stand patient lift.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal system, above knee (AK) or 
hip disarticulation, alignable system (L5920). 
 
You asked the Plan to pre-approve an addition, endoskeletal system, above knee (AK) or hip disarticulation, 
alignable system. You say that the item is medically necessary. The Plan denied your request. The Plan says the 
member was approved for a non-alignable prosthesis system, the requested item is for an alignable system. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an addition, endoskeletal system, above knee (AK) or hip disarticulation, alignable system have 
not been met. Specifically, the member was approved for a non-alignable prosthesis system, the requested item 
is for an alignable system. This means the requested item is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve an addition, endoskeletal system, above knee (AK) or hip 
disarticulation, alignable system (L5920).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to provide continued skilled nursing facility (SNF) services after March 8, 2022. 
 
You asked the Plan to provide SNF care. You say that you need additional SNF care. The Plan denied your 
request. The Plan says that continued SNF care is not medically necessary. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before March 8, 2022. The Plan must pay for SNF services until the 100-day SNF care benefit is 
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to provide continued skilled nursing facility (SNF) services after March 8, 2022.  
 
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.