Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 10 PT visits. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the clinical information provided to us you had no significant changes in 
ankle movement or leg strength. The Plan also says that the provided documentation does not show you need 
the ongoing skills of a physical therapist. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 10 PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the provided documentation indicates that the treatments have been 
repetitive which would not require the continued skill of a licensed therapist regardless if plan is maintenance 
or restorative. The reviewer also found that the already approved visits would generally be accepted as enough 
time to develop a repetitive home exercise plan or for instruction on pain 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 10 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 10 additional physical therapy (PT) visits.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 99284, 96365, 96366, 96367, J2550, J2405, 96372, 
A4244, A6441, A4216, A4209, A4649, A4616, 83380, 81000, 80053, 87426, and 85025. We decided that the 
Plan does not have to pay for procedure codes 80076, A4770, 99070, 36000 and J8499.  
 
You asked the Plan to pay for the services provided. The Plan says that the Medicare rules for payment have 
not been met. 
 
We decided that the Plan has to pay for procedure codes 99284, 96365, 96366, 96367, J2550, J2405, 
96372, A4244, A6441, A4216, A4209, A4649, A4616, 83380, 81000, 80053, 87426, and 85025.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The case file does not indicate why the Plan has upheld their decision to 
deny the services at issue. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for 
procedure codes 99284, 96365, 96366, 96367, J2550, J2405, 96372, A4244, A6441, A4216, A4209, A4649, 
A4616, 83380, 81000, 80053, 87426, and 85025 provided on November 7, 2020.  
 
We also decided that the Plan does not have to pay for procedure codes 80076, A4770, 99070, 36000 and 
J8499. 
 
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 99070 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99070 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
have not been met. 
 
We find that CPT code 36000 may be eligible for payment when billed with code 96365. However, the claim 
does not show that code 36000 was billed with a modifier suitable for payment. We find that CPT code 80076 
was billed with 80053. This code pair has a modifier indicator of 0. This means that code 80076 is not eligible 
for payment.   
 
We find that CPT code A4770 is a packaged code. Payment for this service is packaged into payment for other 
services. There is no separate payment allowed. We find that CPT code J8499is not paid by Medicare when 
submitted on an outpatient claim.  
 Based on the information provided, we decided that the Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 80076, A4770, 99070, 36000 and 
J8499 provided on November 7, 2020. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the vision services provided on August 30, 
2021. 
 
You asked the Plan to waive the cost share for the services provided. You say that you were not aware of the 
cost. The Plan denied your request.  
 
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 $35 
copay for Medicare covered vision services.  
 
The file shows that you received a medical eye exam. You have been asked to pay a $35 copay for the exam. 
You also received eye refraction services. This service is only covered as part of a routine eye exam. The 
services provided fall within the vision care 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 cost share for the vision services provided on August 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. You say that you are used to the device. The Plan 
denied your request. The Plan says you only check your blood sugar 2 times a day. 
 
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 does not indicate that you perform blood glucose 
testing at least four times per day, use insulin with at least three daily injections, or require frequent self-
adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided 
that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair power seat elevation system (E2300). 
 
You asked the Plan to pre-approve the wheelchair power seat elevation system. You say that this item is 
medically necessary. The Plan denied your request. The Plan says this item does not primarily serve a medical 
purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the wheelchair power seat elevation system (E2300).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bilateral upper or lower extremity arterial assessments to 
check blood flow in relation to a blockage (93923) provided on January 11, 2021. 
 
You asked the Plan to pay for bilateral upper or lower extremity arterial assessments to check blood flow in 
relation to a blockage. The Plan denied your request. The Plan says the services are 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 bilateral upper or lower extremity arterial 
assessments to check blood flow in relation to a blockage. Our reviewer says that bilateral upper or lower 
extremity arterial assessments to check blood flow in relation to a blockage are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is no documentation as to why a 
second study of the same kind would be required on the same day. Review of the enrollees notes suggest that 
portions may be computer-generated. In this case treatment item #6 other specified symptoms and signs 
involving the circulatory and respiratory systems was addressed by ordering procedure: ABI segmental in-
house item #11 entitled atherosclerosis of native arteries of extremities with intermittent claudication, 
bilateral legs was also addressed by procedure: ABI segmental in-house.  It is possible that these separate 
treatment items generated 2 separate orders for the same study. However, from a medical standpoint, there 
would be no reason to obtain two of the same study on the same day. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bilateral upper or lower extremity arterial assessments to check blood flow in 
relation to a blockage have not been met. Therefore, we decided that the Plan does not have to pay for bilateral 
upper or lower extremity arterial assessments to check blood flow in relation to a blockage (93923) provided on 
January 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pulsed irrigation and evacuation systems (E0350, 
E0352). 
 
You asked the Plan to pre-approve the pulsed irrigation and evacuation systems. You say that the items are 
medically necessary. The Plan denied your request. The Plan says these are not covered items. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the pulsed irrigation and evacuation systems (E0350, 
E0352).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoulder elbow wrist hand orthosis (L3960) provided to the 
enrollee on December 23, 2021. 
 
You asked the Plan to pay for the orthosis. You say that this was medically necessary. The Plan denied your 
request. The Plan says the documentation submitted did not sufficiently support the billed supply code. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 orthosis. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer found the review has determined that the orthosis at issue in this case was not 
medically reasonable or necessary. There was no evidence that it was validly ordered by the treating physician. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for a shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on December 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intermittent urinary catheter (A4351 x 11880), and 
the lubricant (A4402 x 264). 
 
You asked the Plan to pre-approve the intermittent urinary catheter and lubricant. You say that the items are 
medically necessary. The Plan denied your request. The Plan says this request exceeds the maximum 
allowance. Urological supplies are dispensed three months at a time; it is not appropriate to approve a years' 
worth of supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that the maximum allowed quantity of A4351 is 200 
per a month. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the intermittent urinary catheter and lubricant have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the intermittent urinary catheter (A4351 x 11880), and the lubricant (A4402 
x 264).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) sensor. 
 
You asked the Plan to pre-approve the CGM sensor. You say that the item is medically necessary. The Plan 
denied your request. The Plan says you do not use insulin with at least three daily injections. 
 
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 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
continuous glucose monitor (CGM) sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-preferred brand of diabetic testing supplies. 
 
You asked the Plan to pre-approve a non-preferred brand. The Plan denied your request. The Plan says you do 
not meet the criteria for coverage for a non-preferred diabetic supply. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The rules say that plans 
may specify brands and manufacturers as preferred or may limit the DME to only those preferred brands.  
 The requested brand of diabetic testing supplies is not a preferred brand with the Plan. The Plan has preferred 
brands available for the items at issue in this appeal. We found no exception that would require the Plan to pre-
approve a non-preferred. Therefore, we decided that the Plan does not have to pre-approve a non-preferred 
brand of diabetic testing supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the inpatient hospital care provided 
from September 6, 2021, to September 10, 2021. 
 
You asked the Plan to pay an additional amount for the inpatient care. You say that the billing of diagnosis 
code, I50. 43, is supported. The Plan denied your request. The Plan says the billing of diagnosis code, I50. 43, 
is not supported. 
 
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 the billing of diagnosis code I50. 43, defined as 
acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure. 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 an additional amount for the inpatient care. Our reviewer says 
that the billing of diagnosis code, I50. 43, Acute on chronic combined systolic (congestive) and diastolic 
(congestive) heart failure is not supported. Our physician reviewer found that the provided documentation does 
not indicate that the enrollee required treatment for congestive heart failure (CHF) during the dates of service in 
this case.  
 
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 
an additional amount for the inpatient hospital care provided from September 6, 2021, to September 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthrodesis services (22630) provided on December 23, 
2021. 
 
You asked the Plan to pay for the arthrodesis services. You say that you would like this claim reprocessed 
based on medical records. The Plan denied your request. The Plan says this claim has a procedure to procedure 
edit which indicates no modifiers will be allowed with this pairing to bypass the edit. 
 
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 22630 
is a column II code to column I code 22633. This code pairing indicates that no modifiers are able 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 arthrodesis services (22630) provided on December 23, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Remicade 100 mg vial. 
 
You asked the Plan to pre-approve Remicade. You say that this drug is medically reasonable and necessary. 
The Plan denied your request. The Plan says step therapy criteria have not been met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Remicade. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has a 
diagnosis of Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems 
involvement. The Plan requires a trial of Avsola (Infliximab-axxq), Renflexis (Infliximab-abda), or Inflectra 
(Infliximab-dyyb) before they will approve the requested drug.  In this case, it is not clear that the enrollee tried 
and failed treatment with Avsola (Infliximab-axxq), Renflexis (Infliximab-abda), or Inflectra (Infliximab-
dyyb). In addition, the documentation does not support that Avsola (Infliximab-axxq), Renflexis (Infliximab-
abda), or Inflectra (Infliximab-dyyb) would likely be less effective, and/or would likely have adverse effects 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 Remicade have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Remicade 100 mg vial.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient long term acute care hospital 
(LTACH) for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not 
require transfer to a Long-Term Acute Care Hospital (LTACH). 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital for 
pulmonary emboli. The enrollee was transiently intubated/ventilated, but is no longer intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs 
are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 
The enrollee can remain at the current acute care hospital until such time no acute services are required. The 
enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to an inpatient long term acute care hospital (LTACH) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 9, 2021. 
 
You asked the Plan to pay for the services provided. You say that the specimens are received from providers 
and are irreplaceable. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
 The Plan must follow Medicare rules. Medicare rules say that 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. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on May 9, 2021.