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

 
We decided that the Plan does not have to pre-approval additional routine transportation trips. 
 
You asked the Plan to pre-approval additional routine transportation trips. You say that you need transportation 
to get to your medical appointments. The Plan denied your request. The Plan says you have utilized the 
maximum number of transportation trips allowed per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approval additional routine transportation trips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing services (99310) provided on March 8, 2021. 
 
You asked the Plan to pay for nursing services. You say that this claim was billed with the appropriate POS 
code, and these services were necessary. The Plan denied your request. The Plan says the POS code billed for 
this claim is not appropriate in this case; a call was made to the facility, and it was verified that POS code used 
on this claim does not match the one provided by the facility. In addition, there is no prior authorization on file 
for these services. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the POS code billed for this claim is not supported in the record. Based on this information, we 
decided that Medicare rules for coverage of nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for nursing services (99310) provided on March 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and sleeve provided to the 
enrollee on November 11, 2021. 
 
You asked the Plan to pay for the pneumatic compression device and sleeve. You say that this was prescribed 
for use during the enrollee's surgery. The Plan denied your request. The Plan says pneumatic compression 
devices are not covered by Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device 
and sleeve provided to the enrollee on November 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 3, 2022. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with your lab certificate. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because it is not clear how 
the enrollee came to this provider or why testing was needed. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic laboratory tests must be ordered by 
the enrollees treating physician.   We looked at the file and Medicare rules. The record submitted does not include a signed physician order or 
clear intent to order the specific lab services billed on this clam. Based on this information, we decided that 
Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have 
to pay for laboratory testing provided on January 3, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (36000) provided on December 9, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 36000 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 36000 is not separately payable. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services 
(36000) provided on December 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Computerized Tomography (CT scan) on 
January 18, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you were informed that there is no 
charge for radiology services. The Plan denied your request. The Plan says the cost-sharing you are being 
charged is correct. 
 
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 $75 
copay for Medicare-covered Diagnostic Radiological Services received in a providers office or freestanding 
facility. Covered services include but are not limited to: Other outpatient diagnostic tests. 
 
 
 
 You have been asked to pay a $75 copayment for CT scan. CT scans fall within the Outpatient diagnostic tests 
and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
Computerized Tomography (CT scan) on January 18, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services (99310) provided on July 22, 2021. 
 
You asked the Plan to pay for nursing care. You say that this claim was billed correctly and should be paid as 
these services were necessary. The Plan denied your request. The Plan says this claim was billed with an 
incorrect POS code. The enrollee is a resident in a long-term care nursing facility, and therefore the appropriate 
POS code for this claim is 32. 
 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that this claim is not supported as billed. Specifically, this claim was not billed with a POS code which 
reflects where the enrollee was registered inpatient at the time of services. Based on this information, we 
decided that Medicare rules for coverage of nursing care have not been met. Therefore, we decided that the 
Plan does not have to pay for skilled nursing services (99310) provided on July 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PWC, group 2 standard, captains chair, patient weight 
capacity up to and including 300 pounds (CPT code K0823), adjustable height, detachable armrest, complete 
assembly (CPT code E0973) and u-1 sealed lead acid battery, each (CPT code E2365). 
 
You asked the Plan to pre-approve the DME. You say that the enrollee had a stroke that has affected their left 
upper extremity and left lower extremity is weak which has resulted in multiple fails. You state the enrollee's 
lower left foot turns in and they walk on the side of their foot. The Plan denied your request. The Plan says the 
Medicare rules have not been met. 
 
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 DME. Our physician reviewer 
found the enrollee has a neurologic disorder with functional deficits that cannot be overcome by an alternative 
assistive device. Criteria for a power wheelchair are met, however, the documentation indicates the enrollee's 
apartment is very small and there is no documentation to support they have had a specialty evaluation by a 
licensed/certified medical professional, such as a physical or occupational therapist to confirm that they can 
safely use a PWC or that it will fit 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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve PWC, group 2 standard, captains chair, patient weight capacity up to and including 300 pounds 
(CPT code K0823), adjustable height, detachable armrest, complete assembly (CPT code E0973) and u-1 
sealed lead acid battery, each (CPT code E2365).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (76000) provided on December 8, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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 76000 is a column II code to column I code 22514. 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 the services (76000) provided on December 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for MTHFR gene testing (81291) provided on December 2, 
2021. 
 
You asked the Plan to pay for MTHFR gene testing. You say that this was medically necessary. The Plan 
denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for the MTHFR gene for all risk 
factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, is non-covered 
except for pregnant patients. 
 
We looked at the file and Medicare rules. The record does not indicate that the enrollee was pregnant at the 
time this test was provided. Based on this information, we decided that Medicare rules for coverage of MTHFR 
gene testing have not been met. Therefore, we decided that the Plan does not have to pay for MTHFR gene 
testing (81291) provided on December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the otolaryngologist office visit to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the otolaryngologist office visit. You say that the in-network provider is too 
far away from your home. You say you have already worked with the out-of-network doctor and is already 
familiar with you. The Plan denied your request. The Plan says the provider is out-of-network. 
 
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 otolaryngologist office visit. We found no exception that would require the Plan 
to pre-approve the otolaryngologist office visit. Therefore, we decided that the Plan does not have to pre-
approve the otolaryngologist office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 3 standard, multiple power 
option and accessories (K0861, E2361, E1028x2, E2377, E1007, E2311, E0955, E1012, K0040, E2313, 
E2620, E2607). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you are in a lot of pain, 
you are unable to sit for long periods of time and you need frequent position change which was recommended 
by your therapist. You also say without the wheelchair and accessories, your quality of life is suffering. The 
Plan denied your request. The Plan says you do not have a medical need for multiple power options included 
with this wheelchair. 
 
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 a power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found you have a 
neurologic disorder with functional deficits. Criteria for a power wheelchair are met. The documentation does 
not indicate that you have any pressure injuries or require intermittent catheterization of the bladder that would 
necessitate power tilt or recline or a condition that would require power leg rests. The requested electrical 
accessories are not medically necessary as you do not have a need for multiple power accessories that would 
need to be managed via the electrical connectors. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair, group 3 standard, multiple power option and 
accessories (K0861, E2361, E1028x2, E2377, E1007, E2311, E0955, E1012, K0040, E2313, E2620, E2607).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mental health visit to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the mental health visit. You say that you requested the out-of-network 
doctor because you like the fact that he is a male and you need a male's perspective in your life at this time. The 
Plan denied your request. The Plan says the requested provider is not a network provider, nor is he contracted 
with the Plan to provide mental health services. 
 
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 
a mental health visit to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the Urolift procedure. 
 
You asked the Plan to pre-approve the Urolift procedure. You say that this requested procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says that there are 
contraindications for this procedure and coverage cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Urolift procedure. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a 70-year-old male with acute urinary retention. His current 
management is with clean intermittent catheterization and tamsulosin. He is only able to void small quantities 
between catheterizations. The cystoscopy on April 12, 2022, reveals trilobar benign prostatic hyperplasia 
(BPH) with obstruction (lateral lobes and 1cm. median lobe). The UroLift System is currently indicated for the 
treatment of symptoms due to urinary outflow obstruction secondary to BPH, including lateral and median lobe 
hyperplasia, in men 45 years of age or older. The records show that these criteria have 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 Urolift procedure have been met. Therefore, we decided that the Plan has to 
pre-approve the Urolift procedure.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for colonoscopy provided on November 10, 
2021. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that you were told there would be no 
copayment for the service. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $260 
copayment for each Medicare covered outpatient hospital services.  
 
You have been asked to pay $260 copayment for colonoscopy. Colonoscopys fall within the Outpatient 
hospital 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 colonoscopy 
provided on November 10, 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 member currently meets IRF admission criteria 
under the Centers for Medicare and Medicaid Services (CMS) guidelines. The Plan denied your request. The 
Plan says based on Medicare guidelines, 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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that the patient 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on March 
16, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you do not want to pay the 
specialist copayment for someone who is not an MD. 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 $40 
copayment for services obtained from a specialist, including treatment by a nurse practitioner or physician's 
assistant.  
 
You have been asked to pay a $40 copayment for the office visit. The office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist office visit provided on March 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the heart (75571). 
 
You asked the Plan to pre-approve a CT of the heart. The Plan denied your request. The Plan says Medicare 
does not cover the requested study for screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT of the heart. Our reviewer says 
that a CT of the heart is not reasonable and necessary. Our physician reviewer found the enrollee has no cardiac 
symptoms. Our reviewer also found that as such, the Centers for Medicare & Medicaid Services (CMS) does 
not provide coverage for a CT coronary scoring as a screening test. 
 
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 CT of the heart have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomography (CT) of the heart (75571).