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

 
We decided that the Plan has to pre-approve a computed tomography (CT) of the chest. 
 
You asked the Plan to pre-approve a CT of the chest. You say that this scan is very important because you 
would like the spots that were found on your lungs monitored as soon as possible in case action is needed. The 
Plan denied your request. The Plan says that Medicare criteria are not met, as there is not sufficient information 
provided to determine that the chest CT scan is reasonable and necessary. 
 
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 chest. Our reviewer says 
that a CT of the chest is reasonable and medically necessary. Our physician reviewer found you have a 1.1-
centimeter nodule that is new compared to a CT in 2007. A 3-to-4-month CT to assess for stability would not 
be unreasonable based on the National Comprehensive Cancer Network (NCCN) Guidelines, Version 1.2023, 
Lung Cancer Screening. 
 
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 chest have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) of the chest.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27447 billed for date of service April 11, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the code is separately payable. The Plan denied 
your request. The Plan says an appropriate modifier was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 We find that CPT code 27447 was billed within the 10-day global surgical period for procedure code 64640. 
The claim at issue was not billed with a modifier suitable for payment. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 27447 billed for date of service April 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion, subcutaneous cardiac rhythm monitor, 
including programming (33285). 
 
You asked the Plan to pre-approve the implantable cardiac loop recorder. You say that please see attached your 
office note, cardiac imaging studies and cardiac monitor. In this setting an implantable loop recorder would be 
medically appropriate. The Plan denied your request. The Plan says under Medicare guidelines the requested 
service does not meet the requirements for approval. 
 
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 implantable cardiac loop recorder. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee had no history of atrial fibrillation, nor were any 
significant cardiac arrhythmias noted on ECG monitoring. A recent randomized clinical trial found that 
continuous monitoring for atrial fibrillation with an ILR (followed by treatment with oral anticoagulation if 
atrial fibrillation was detected) was not superior to usual care in reducing stroke or systemic embolism among 
patients at high risk of stroke but without a known prior history of atrial fibrillation. At this time, insertion of 
an ILR would not be considered medically appropriate and necessary in this enrollees clinical management. 
 
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 implantable cardiac loop recorder have not been met. Therefore, we decided 
that the Plan does not have to pre-approve insertion, subcutaneous cardiac rhythm monitor, including 
programming (33285).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a general use wheelchair seat cushion, a 
standard hemi (low seat) wheelchair, a general use wheelchair back cushion, and a manual wheelchair 
accessory provided from January 9, 2022, to June 9, 2022. 
 
You asked the Plan to waive the copayment for a general use wheelchair seat cushion, a standard hemi (low 
seat) wheelchair, a general use wheelchair back cushion, and a manual wheelchair accessory. You say that you 
are being billed for a wheelchair that you have never used. You also say that you have asked the company to 
pick up the equipment. You do not feel you should have been charged for something you did not use. The Plan 
denied your request. The Plan says this cost sharing was charged 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 10% 
coinsurance of the approved amount for durable medical equipment (DME) and related medical supplies.  
 
You have been asked to pay 10% coinsurance each month for a general use wheelchair seat cushion, a standard 
hemi (low seat) wheelchair, a general use wheelchair back cushion, and a manual wheelchair accessory.  
 
Claim Number: Date of Service: Allowed Amount: Coinsurance: 
220225423226 January 9, 2022 $384.92 $38.50 
220223212906 February 9, 2022 $46.35 $4.64 
220317126899 March 9, 2022 $46.35 $4.64 
220415684970 April 9, 2022 $46.35 $4.64 
220514257051 May 9, 2022 $46.35 $4.64 
220617295138 June 9, 2022 $46.35 $4.64 
 Total: $616.67 $61.70 
 
 
This item/service falls within the durable medical equipment (DME) and related medical 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 a general use wheelchair seat cushion, a 
standard hemi (low seat) wheelchair, a general use wheelchair back cushion, and a manual wheelchair 
accessory provided from January 9, 2022, to June 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 13, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed until July 20, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on July 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-covered ambulance mileage (A0888) provided on 
June 13, 2022. 
 
You asked the Plan to pay for the non-covered ambulance mileage. You say that you do not believe there was 
any other way possible that you could have been transported by, because your left leg's femur bone was 
completely broken. The Plan denied your request. The Plan says this service is not a Medicare covered 
ambulance mileage 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 A0888 is non-covered ambulance mileage, per mile. 
 
We find that CPT code A0888 is not supported in the medical record. Specifically, code A0888 is not 
supported as it has a status indicator of N, which indicates it is not covered. Based on this information, we 
decided that Medicare rules for coverage of the non-covered ambulance mileage have not been met. Therefore, 
we decided that the Plan does not have to pay for the non-covered ambulance mileage (A0888) provided on 
June 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the knee. 
 
You asked the Plan to pre-approve an MRI of the knee. You say that the enrollee's symptoms have not 
resolved, and you would like an MRI to be approved. The Plan denied your request. The Plan says the 
requested MRI cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the knee. Our reviewer says 
that an MRI of the knee is not medically necessary and reasonable for the diagnosis and treatment for the 
enrollee's clinical condition at this time. Our physician reviewer found the record indicates that the enrollee has 
osteoarthritis of the knee and is being referred for knee replacement. The record provided does not include a 
physical examination of the knee at the time the requested test was determined to be necessary. Our reviewer 
found that the record does not indicate how the requested test will alter the enrollee's management at this time. 
The elements of the coverage criteria are not satisfied. Our physician reviewer also found that the requested 
service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the knee have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a magnetic resonance imaging (MRI) of the knee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 14, 2022, to 
February 20, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
diagnoses N17.9 (Acute kidney injury, unspecified) and G93.41 (Metabolic encephalopathy) are valid for this 
encounter. The Plan denied your request. The Plan says the principal diagnosis N17.9 (Acute kidney injury, 
unspecified) and secondary diagnosis G93.41 (Metabolic encephalopathy) are not supported in the medical 
record, resulting in a lower DRG being paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis N17.9 (Acute kidney injury, 
unspecified) and secondary diagnosis G93.41 (Metabolic encephalopathy). 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that principal diagnosis N17.9 (Acute kidney injury, unspecified) and secondary diagnosis G93.41 (Metabolic 
encephalopathy) are not supported in the medical record. Our physician reviewer found the patient is an 84-
year-old female with Parkinson's who presented to the hospital with tremors, nausea, and intermittent rapid 
breathing. She was found to have Blood Urea Nitrogen (BUN) of 15, Cr 1.27, and was treated with fluids. 
Repeat BUN was 13, Creatinine (Cr) 1.08. These changes in Cr does not show an increase of 1.5 times the 
patient's baseline (Cr. 1.07) nor shows a rapid increase of 0.3 during the 48 hours while admitted, to meet the 
criteria for acute kidney injury. Also, records describe the patient as alert and oriented x 3. Although it was 
reported that the patient had delirium and hallucinations, there was insufficient evidence to support this was 
related to a metabolic process to support the diagnosis of metabolic encephalopathy as it didn't improve by 
discharge. Therefore, neither principal diagnosis N17.9 (Acute kidney injury, unspecified) nor secondary 
diagnosis G93.41 (Metabolic encephalopathy) were supported in the provided medical records.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on February 14, 2022, to February 20, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-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 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 an office visit provided on June 8, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided from 
February 1, 2022, to February 28, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the item rendered is not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that a PCD coded as E0675 to treat peripheral 
arterial disease is not eligible for reimbursement. 
 
 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided from February 1, 2022, to February 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies provided on June 12, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you disagree with the Plans 
denial. The Plan denied your request. The Plan says the documentation does not support a relationship between 
the ordering provider and 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 relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that there is no documentation to support a relationship between the 
enrollee and the ordering physician. 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 provided on June 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for mammography on July 13, 2022. 
 
You asked the Plan to waive the copayment for mammography. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says this cost sharing was charged 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 a $20 
copayment for each basic imaging service (e.g., general x-rays or ultrasound). Covered services include, but are 
not limited to other outpatient diagnostic tests. 
 
You have been asked to pay a $20 copayment for mammography. This item/service 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 mammography on July 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen validity testing (83789) provided on April 11, 
2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the specimen validity testing (83789) provided on April 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will receive the appropriate level of care 
in the IRF setting. The Plan denied your request. The Plan says the request 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services are medically necessary for the 
enrollee's diagnosis. The Plan denied your request. The Plan says the request 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99284), services provided 
between 10 pm and 8 am (99053), and incision and drainage of abscess (10060) provided on March 3, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were rendered to the enrollee in 
good faith. You also say that this claim should be paid. The Plan denied your request. The Plan says the claim 
was not submitted timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the physician services was not filed until May 5, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the emergency department visit (99284), services provided between 10 pm 
and 8 am (99053), and incision and drainage of abscess (10060) provided on March 3, 2021.