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

 
We decided that the Plan does not have to pay for imaging services provided on October 5, 2022. 
 
You asked the Plan to pay for imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 92136 is ophthalmic biometry by partial coherence 
interferometry with intraocular lens power calculation. 
 
We asked our coder 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 imaging services provided. Our reviewer says that 
documentation does not support the billed code.  
 Our reviewer found an ophthalmic diagnostic test that measures the curvature of the cornea and the depth of the 
anterior chamber in addition to the axial length of the eye, without ultrasound, is not included in the 
documentation for this date of service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of imaging services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for imaging services provided on October 5, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve image-guided radiation therapy. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no reference to mobility of structures to justify intensity modulated 
radiation therapy/image-guided radiation therapy (IMRT/IGRT) over three-dimensional conformal radiation 
therapy (3D-CRT). 
 
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 therapy. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that it is safe to say that intensity modulated radiation therapy (IMRT) is not experimental, but rather a 
useful tool available to radiation oncologists to potentially reduce toxicity and improve the lung and skin dose 
distributions. With IMRT, IGRT is standard (and a bundled technical service). It is plausible that with this 
patient undergoing supraclavicular nodal radiation, IMRT would be necessary for dose homogeneity. 
 
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 therapy have been met. Therefore, we decided that the Plan has to pre-
approve image-guided radiation therapy.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided on 
November 10, 2022. 
 
You asked the Plan to pay for the CGM supplies. You say that the supplies were medically necessary for the 
enrollee. The Plan denied your request. The Plan says the criteria have not been met.  
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM supplies have not been met. Therefore, we decided that the Plan does not have to pay for the 
continuous glucose monitor (CGM) supplies provided on November 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuation of an observation level of care provided from 
July 9, 2022, to July 20, 2022. 
 
You asked the Plan to pay for continuation of an observation level of care. You say that continuation of  an 
observation level of care was medically necessary. The Plan denied your request. The Plan says the enrollee 
was medically stable as of July 8, 2022, and continuation of the observation level of care was 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 pay for continuation of an observation level of care. 
Our reviewer says that continuation of an observation level of care is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee was admitted to observation on 
July 3, 2022, with failure to thrive, dehydration, and acute hypernatremia. Intravenous (IV) normal saline was 
administered. On July 9, 2022, it is documented that the acute hypernatremia secondary to dehydration had 
resolved. The documentation does not support that the continuation of observation level of care from  
July 9, 2022, through July 20, 2022, was medically necessary for the enrollee in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of an observation level of care have not been met. Therefore, we 
decided that the Plan does not have to pay for continuation of an observation level of care provided from 
July 9, 2022, to July 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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, for 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 November 7, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided March 28, 2022, to March 
30, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnostic services provided to a beneficiary by 
the admitting hospital, or by an entity wholly owned or wholly operated by the admitting hospital (or by 
another entity under arrangements with the admitting hospital), within 3 days prior to and including the date of 
the beneficiary's admission are deemed to be inpatient services and included in the inpatient payment. 
 
 We looked at the file and Medicare rules. Review of the file shows that these outpatient services were provided 
within 3 days prior to the enrollees inpatient admission. This means these services are included in the inpatient 
payment. Based on this information, we decided that Medicare rules for coverage of the outpatient services 
have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient services 
provided March 28, 2022, to March 30, 2022.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the Group 3 power wheelchair (K0861) and accessories (E2363, 
E1028, E2377, E2313, E1007, E2311, E2620, E0956, E0955, E0953, E0960, E0950, E0978). We also decided 
that the Plan does not have to pre-approve the power seating and standing features (E2300, E2301) and the 
convenience accessories (K0108).  
 
You asked the Plan to pre-approve a Group 3 power wheelchair and accessories. You say that you purchased 
your current power wheelchair on your own and did not go through your insurance. The Plan denied your 
request. The Plan says that your current power wheelchair has not met the five-year RUL. 
 
We decided that the Plan has to pre-approve the Group 3 power wheelchair (K0861) and accessories 
(E2363, E1028, E2377, E2313, E1007, E2311, E2620, E0956, E0955, E0953, E0960, E0950, E0978).  
 
The Plan must follow Medicare rules. The rules say that the RUL of DME is determined through program 
instructions. In the absence of program instructions, carriers may determine the RUL, but in no case can it be 
less than five years.  
 
The record shows you purchased your current power wheelchair on your own through eBay. The RUL of five 
years for DME does not apply to items that were not approved by Medicare or the Plan. Therefore, we decided 
that the Plan has to pre-approve the Group 3 power wheelchair (K0861) and accessories (E2363, E1028, 
E2377, E2313, E1007, E2311, E2620, E0956, E0955, E0953, E0960, E0950, E0978).  
 
We also decided that the Plan does not have to pre-approve the power seating and standing features 
(E2300, E2301) and the convenience accessories (K0108). 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The power seating and standing features and convenience accessories do not serve a purpose that is primarily 
medical in nature. Therefore, we decided that the Plan does not have to pre-approve the power seating and 
standing features (E2300, E2301) and the convenience accessories (K0108). 
 
 
 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service November 2, 
2022. 
 You asked the Plan to pay for procedure code 86077. You say that this was medically necessary. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service November 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and appliances provided 
on September 13, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and appliances. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the items rendered are not a covered benefit 
in this place of service. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the pneumatic compression device and appliances was used in an ambulatory surgical 
center. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and 
appliances provided on September 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (86077) provided on August 16, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code 86077 is not supported in the medical record. Specifically, the claim was billed with an 
outpatient place of service, however the records show that the enrollee was an inpatient at the time this service 
was provided. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (86077) provided on 
August 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management services identified with 
procedure code 99490 for date of service October 22, 2021. 
 
You asked the Plan to pay for the chronic care management services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as 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, the CPT Code Manual definition of code 99490 is chronic care management services with the 
following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or 
until the death of the patient, chronic conditions place the patient at significant risk of death, acute 
exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, 
revised, or monitored; first 20 minutes of clinical staff time directed by a physician or other qualified health 
care professional, per calendar month. 
 
We find that CPT code 99490 is not supported in the medical record. Specifically, this service is covered when 
provided during a comprehensive evaluation and management visit, annual wellness visit, or initial preventive 
physical exam. The documentation does not support that these services were provided during one of these 
instances. Based on this information, we decided that Medicare rules for coverage of the chronic care 
management services have not been met. Therefore, we decided that the Plan does not have to pay for the 
chronic care management services identified with procedure code 99490 for date of service October 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the device is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide x's 8 visits. 
 
You asked the Plan to pre-approve the aide services. You say that the request for a home health aide x8 is 
medically necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
  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 aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found there is no 
documentation that the requested home health aide services meet Medicare criteria for reasonable and 
necessary to the treatment of the patient's illness or injury by the skilled professional staff. Enrollee is not 
receiving any skilled home health nursing or therapy services; without skilled home health nursing or therapy 
services in place, home health aide services are not covered 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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health aide x's 8 visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network orthopedic referral. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are network providers available. 
 
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 out-of-network orthopedic referral.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for durable medical equipment provided on October 3, 2022. 
 
You asked the Plan to pay for the services. You say that you submitted medical records for review. The Plan 
denied your request. The Plan says that there is no evidence that this item was delivered. 
 
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's denial is not sufficient in this case. The provider sent in a 
manufacturer's invoice and a packing slip for the items that were denied. The plan's denial states that the 
tracking number used for the items shows as "Label Created, not yet in system" when you search for the 
tracking number on the United States Postal Service (USPS) site. USPS reuses tracking numbers after 120 
days. It has been more than 120 days since the date of service. Therefore, using the information available about 
the tracking number is invalid. The records also show that the item was delivered to the enrollee. Therefore, we 
decided that the Plan has to pay for durable medical equipment provided on October 3, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine eye exam provided on December 6, 2022. 
 You asked the Plan to pay for the routine eye exam. You say that the only reason you needed this eye exam 
was because your glaucoma was not diagnosed during your previous exam. You also say that you should not be 
responsible for this bill. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. Routine eye exams are covered once per 12 months. Based on this 
information, we decided that the Plan's rules for coverage of the routine eye exam have not been met. The 
record shows that the Plan paid for a routine eye exam that you received within 12 calendar months of the date 
of service in this case. Therefore, we decided that the Plan does not have to pay for a routine eye exam 
provided on December 6, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for group therapy and psychotherapy provided from  
May 6, 2022, to May 9, 2022. 
 
You asked the Plan to pay for group therapy and psychotherapy. You say that the care was medically 
necessary. The Plan denied your request. The Plan says this provider is a non-Medicare approved/certified 
Substance Abuse Rehabilitation Facility. 
 
The Plan must follow Medicare rules. Medicare rules say that a Substance Abuse Facility is not 
eligible to participate in the Medicare program. 
 
 We looked at the file and Medicare rules. The provider at issue in this case is a Substance Abuse Facility. 
Medicare says that a Substance Abuse Facility is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for group therapy and psychotherapy provided from  
May 6, 2022, to May 9, 2022.