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

 
We decided that the Plan does not have to pre-approve the MyoPro Orthosis for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested MyoPro Orthosis is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the MyoPro is not known to be effective, based on scientific evidence, professional standards and expert 
opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on 
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the 
long term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is 
insufficient evidence in the literature that this device will increase  participation in bimanual activities. At this 
time, the requested robotic orthosis is not proven to be more beneficial for treatment of the patient's medical 
condition/function of hemiparesis after stroke than any available standard therapy such as conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, conventional 
muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable and necessary 
for the diagnosis or treatment of an illness or injury or  to improve the functioning of a malformed body 
member. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the MyoPro Orthosis for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you have been referred and admitted to 
hospice for palliative care. You do not require skilled nursing and/or skilled therapy services on a daily basis. 
You do not have any parental medication; complex wound care or nutrition given via a feeding tube. 
 
We looked at this physician's review, the file, and Medicare rules. Please note that you have elected hospice 
and the payment for these services would be the responsibility of Original Medicare. Based on this information, 
we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on November 3, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that since retro-authorization is not allowed, you were 
unable to initiate authorization on time, as it is impossible to obtain prior authorization. You also say that in 
this scenario you should not be penalized. The Plan denied your request. The Plan says the rendering provider 
is a non-participating provider and there is no referring provider involved in these services. The Plan also says 
they did not authorize any services for a rendering provider nor for this facility. 
 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 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 drug testing provided on November 3, 2021, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gas dilution or washout for determination of lung volumes 
and, when performed, distribution of ventilation and closing volumes (94727) Diffusing capacity (e.g., carbon 
monoxide, membrane) (List separately in addition to code for primary procedure) (94729) Spirometry, 
complete (94010) provided July 12, 2021. 
 
You asked the Plan to pay for the pulmonary diagnostic tests. You say that as per our coding department the 
procedure code is consistent without the modifier billed, and the procedure code compatible without modifier 
The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding 
regulations. 
 
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 CPT codes 94010, 94727, 94729 are not supported in the medical record. Specifically, Medicare procedure requires modifier 26 per Medicare guidelines. Per the above Medicare guidelines, CPT 
codes 94010, 94727 and 94729 have a PCTC Indicator of 1 and the claim POS of 21 for inpatient hospital. 
Based on this information, we decided that Medicare rules for coverage of the pulmonary diagnostic tests have 
not been met. Therefore, we decided that the Plan does not have to pay for gas dilution or washout for 
determination of lung volumes and, when performed, distribution of ventilation and closing volumes (94727) 
Diffusing capacity (e.g., carbon monoxide, membrane) (List separately in addition to code for primary 
procedure) (94729) Spirometry, complete (94010) provided July 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthosis. 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that the requested MyoPro orthosis is medically 
necessary. The Plan denied your request. The Plan says the requested MyoPro orthosis is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a MyoPro orthosis. Our reviewer says 
that the requested MyoPro orthosis is not medically necessary. Our physician reviewer found the MyoPro is not 
known to be effective, based on scientific evidence, professional standards and expert opinion, in improving 
health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this 
enrollee, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the 
literature that this device will increase participation in bimanual activities. 
 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 MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks. 
 
You asked the Plan to pre-approve medial branch blocks. The Plan denied your request. The Plan says 
Medicare criteria for medical necessity has not been met. There is no current description of the member's pain, 
no documentation of the member's functional deficit(s) and no current physical exam performed since  
July 2021. The member has radicular pain that has not been treated.  
 The Plan follows Medicare rules.  
 
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 medial branch blocks. Our reviewer 
says that medial branch blocks are not medically necessary. Our physician reviewer found that the enrollee has 
radicular pain that has not been treated. In addition, there is non-facet pathology noted on the imaging studies 
that identify three nerve sheath tumors to the lumbar spine that could be the source of the enrollees pain. 
The enrollee does not meet the criteria of the LCD. The request is considered not medically reasonable or 
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 medial branch blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve medial branch blocks.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Hospital outpatient clinic visit provided on August 30, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Hospital outpatient clinic visit. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network and it 
was determined these services were not urgent or emergent. 
 
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 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 Hospital outpatient clinic visit provided on August 
30, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 16, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this test is unlikely to impact therapeutic decision-making in the clinical management of the 
patient. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the F1Heme test is a proven medically necessary covered benefit for comprehensive genomic profile 
testing for cancer to identify potential targeted therapy options in beneficiaries with a diagnosis of acute myeloid leukemia, myelodysplastic syndromes, myelodysplastic syndromes/myeloproliferative neoplasms and 
myeloproliferative neoplasms. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on August 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (72100) provided October 27, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim was filed with an invalid modifier. 
 
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 72100 is not supported in the medical record. Specifically, both the professional and 
technical component of the mobile x-ray services were billed. The service should be billed without a modifier. 
Based on this information, we decided that Medicare rules for coverage of the radiology services have not been 
met. Therefore, we decided that the Plan does not have to pay for radiology services (72100) provided October 
27, 2021.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for initial observation care (99220) provided on June 17, 2021. 
 
You asked the Plan to pay for initial observation care. You say that this observation was provided during a new 
admission. The Plan denied your request. The Plan says that initial care can only be paid once per provider. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has denied the initial observation care on June 17, 2021 based on initial 
observation care provided on June 14, 2021; however, the record shows that the enrollee was discharged from 
that observation stay on June 15, 2021, and the services at issue were provided during a separate admission. 
The Plan has not provided information to support that these services should be billed as part of the same 
admission. Therefore, we decided that the Plan has to pay for initial observation care (99220) provided on June 
17, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hereditary assessment for cardiac conditions provided to 
the enrollee on October 29, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is no Medicare benefit for screening cardiovascular risk assessment testing for 
asymptomatic (without signs or symptoms of disease) patients. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the review indicates that there is no Medicare benefit for screening cardiovascular risk assessment testing 
for asymptomatic(without signs or symptoms of disease) patients. Screening asymptomatic patients for cardiovascular risk is statutorily excluded by Medicare. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a hereditary assessment for cardiac conditions provided to the enrollee on October 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotics (L1971, L3170) provided on December 8, 2021. 
 
You asked the Plan to pay for orthotics. You say that these items are supported in the records. The Plan denied 
your request. The Plan says the submitted records are not sufficient to support these items. 
 
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 proof of delivery for the supplies provided in this case. The submitted 
records do not include an itemized delivery ticket showing the specific items provided. 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 orthotics (L1971, L3170) provided on December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99205) provided January 26, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed. 
 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 99205 
is a column II code to column I code 94060. 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 physician services (99205) provided January 26, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on May 19, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you were told the provider was in-
network and then received a letter a week later stating that the provider was out-of-network. The Plan denied 
your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $105 for 
the ultrasound.  
 
You have been asked to pay $105. An ultrasound 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 the 
ultrasound provided on May 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiovascular genetic screening panel provided to the 
enrollee on May 17, 2021. 
 
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your 
request. The Plan says this was initiated by the laboratory, not the treating physician. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the reviewed documentation indicates that the documentation submitted on appeal indicates the 
cardiovascular genetic screening panel was initiated by the laboratory and not by the enrollee's treating 
physician nor following a consultation or evaluation by the enrollee's treating physician. The provider's office 
reported they did not order this testing.  The records did not support a valid physician order was present for this testing. 
 
We looked at this physician's review, the file, and Medicare rules. The documentation submitted did not 
include a physician order provided by the treating physician. 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 pre-approve a cardiovascular genetic screening panel provided to the enrollee on May 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transcutaneous electrical nerve stimulation (tens) device, 
four or more leads, for multiple nerve stimulation (E0730) provided October 6, 2020. 
 
You asked the Plan to pay for the TENS device. You say that you request that this claim be reconsidered and 
overturned. The Plan denied your request. The Plan says Transcutaneous Electric Nerve Stimulation (TENS) 
units and garments and supplies for chronic back pain are not a Medicare covered benefit. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the TENS device have not been met. Therefore, we decided that the Plan does not have to pay for 
transcutaneous electrical nerve stimulation (tens) device, four or more leads, for multiple nerve stimulation 
(E0730) provided October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
November 20, 2020 to December 17, 2020. 
 
You asked the Plan to pay for home health services. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says Claim/service lacks 
information or has submission/billing errors. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the claim 
was billed with missing, incomplete or invalid revenue codes. Therefore, we decided that the Plan does not 
have to pay for the home health services provided to the enrollee from November 20, 2020 to December 17, 
2020.