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

 
We decided that the Plan does not have to pay for the genetic testing provided on April 27, 2022, billed with 
codes 86171, 82784, 86003, 82787, 86001, 82785, 83516, 86332, 86160. 
 
You asked the Plan to pay for the genetic testing billed. You say that please review all medical documentation 
and process the attached claims. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 27, 2022, billed with codes 86171, 82784, 86003, 82787, 86001, 82785, 83516, 86332, 86160.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
(E0601) purchased July 19, 2022. 
 
You asked the Plan to pay for the CPAP device. You say that you paid $880 for the CPAP on July 19, 2022 and 
have not been reimbursed. You were told that the Plan does not cover this expense, but you see that CPAP 
devices is covered by Medicare. The Plan denied your request. The Plan says the equipment was purchased 
from a provider who is not certified for Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure 
(CPAP) device (E0601) purchased July 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month, (e.g., 
TENS, NMES) (A4595) and lead wires, (e.g., apnea monitor), per pair (A4557) provided June 15, 2022. 
 
You asked the Plan to pay for the the electrical stimulator supplies. You say that the prescribing physician 
recommends an extended lifetime use of equipment as they are diagnosed with chronic pain and compromised 
mobility without the option for surgical correction. The Plan denied your request. The Plan says evidence of 
misrepresentation. There is no evidence to support the ordering provider is treating the enrollee. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. Specifically, the Plan made outreach to the 
provider's office and confirmed that the physician does not know the enrollee. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month, (e.g., TENS, NMES) 
(A4595) and lead wires, (e.g., apnea monitor), per pair (A4557) provided June 15, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the intraoperative neuromonitoring services provided on April 4, 2022. 
 
You asked the Plan to pay for the monitoring services. You say that the technical charges are payable. The Plan 
denied your request. The Plan says that Medicare may not pay for the technical component of radiology service 
furnished to a hospital outpatient. 
 
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. 
 
We looked at the file and the rules. A claim was not provided by the Plan to show the billing information for 
the services at issue, such as place of service billed. The Plan has not provided the rules they used in their 
determination to deny services. There is insufficient information to determine if the ruling the Plan used is 
applicable in this case. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for 
the intraoperative neuromonitoring services provided on April 4, 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.
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 you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) 
services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the document does not support medical necessity for admission to an IRF. The 
enrollee's rehab needs can be safely met in an alternate and low intensity setting such as in an SNF.  
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a steroid injections in the spine of the neck (62321). 
 You asked the Plan to pre-approve a steroid injections in the spine of the neck. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when the requirements listed in the Medicare Rules section 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 a steroid injections in the spine of the 
neck. Our reviewer says that the service is not medically necessary. Our physician reviewer found there has 
been no documentation of the inability to tolerate noninvasive conservative care or medical documentation of 
failure to respond to four (4) weeks of non-invasive conservative 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 a steroid injections in the spine of the neck have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a steroid injections in the spine of the neck (62321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty walker. 
 
You asked the Plan to pre-approve a heavy-duty walker. You say that your other walker will not fold. The Plan 
denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a heavy-duty walker. Your current heavy-duty walker serves the same purpose as 
the requested heavy-duty walker. Therefore, we decided that the Plan does not have to pre-approve a heavy-
duty walker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the requested ventilator is not medically necessary. Our physician reviewer found The Life2000 device is 
not a true ventilator because it is not capable of providing full ventilatory support. There is inadequate evidence 
of benefit in the treatment of Chronic Obstructive Pulmonary Disorder. This patient does not have an arterial 
blood gas showing chronic carbon dioxide retention. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0429-SH, A0425-SH) provided on 
January 14, 2022. 
 
You asked the Plan to pay for ambulance services. You say that these services were necessary and should be 
paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 26, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for ambulance services have not been met. 
Therefore, we decided that the Plan does not have to pay for ambulance services (A0429-SH, A0425-SH) 
provided on January 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-spinal electrical osteogenesis stimulator device. 
 
You asked the Plan to pre-approve osteogenesis stimulator. You say that this is medically necessary. The Plan 
denied your request. The Plan says the documentation does not show that the enrollee's fracture has not healed 
on X-Ray after 90 days. 
 
The Plan follows Medicare rules. Medicare rules state that non-spinal electrical osteogenesis stimulators are 
only covered if certain 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 osteogenesis stimulator. Our reviewer says that the enrollee does not meet the Medicare criteria for an osteogenesis stimulator. Our physician 
reviewer found the records do not include the minimum required two sets of radiographs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of osteogenesis stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a non-spinal electrical osteogenesis stimulator device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93000 billed for date of service April 6, 
2022. 
 
You asked the Plan to pay for procedure code 93000. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 93000 is bundled into payment for code 93245. 
 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 93000 
is a column II code to column I code 93245. 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 93000 billed for date of service April 6, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on April 1, 
2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy services 
(90832) provided on April 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service February 21, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service February 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC). 
 
You asked the Plan to pre-approve the requested PWC. You say that you feel that you need to use the PWC 
outside the home should be considered because these tasks are a part of life, and you are not able to complete 
them without the PWC. The Plan denied your request. The Plan says there is not sufficient evidence that the 
PWC is needed for use in the home, as a manual wheelchair could be used for in-home activities. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 requested PWC. Our reviewer says 
that the documentation does not support that the Medicare coverage criteria are met in this case. Our physician 
reviewer found the enrollee is a 68-year-old male with a medical history including diabetes mellitus, 
hypertension, and previous stroke who is requesting authorization for a group 2 power wheelchair. The documentation does not support that the enrollee is unable to use an alternative assistive device or a manual 
wheelchair for mobility-related self-care tasks in the home. 
 
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 requested PWC have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Group 2 power wheelchair (PWC).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy provided on December 10, 2021, by an 
out-of-network provider. 
 
You asked the Plan to pay for occupational therapy. You say that the enrollee needed medical treatment at the 
time of service. You say that the attached medical records should be reviewed, and the claim should be paid as 
soon as possible. The Plan denied your request. The Plan says prior authorization was required but not 
obtained.  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 contract with the Plan also says that you must get a referral 
from your primary care physician prior to getting care from out-of-network providers via your Place of Service 
(POS) benefit. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for occupational therapy provided on December 10, 
2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a limited oral evaluation (D0140) provided on April 13, 
2022. 
 
You asked the Plan to pre-approve a limited oral evaluation (D0140). You say that you are appealing the 
denial. The Plan denied your request. The Plan says the service is not covered under the member's contract 
under any normal circumstances. 
 
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. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
limited oral evaluation (D0140) provided on April 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Humira pen. 
 
You asked the Plan to pre-approve Humira. You say that the enrollee is in clinical remission on Humira. The 
Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve a Humira pen.  
 Benefits for Humira may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided March 17, 2022. 
 You asked the Plan to pay for the laboratory services. You say that please review the claim along with the 
medical records, as HCPCS denied stating the HCPCS was experimental. However, your facility deemed the 
services medically necessary The Plan denied your request. The Plan says payment for this service was 
included in the payment to the facility. 
 
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 find that the laboratory is not supported in the medical record. Specifically, payment for this 
service was included in the payment to the facility. Based on this information, we decided that Medicare rules 
for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory services provided March 17, 2022.