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

 
We decided that the Plan does not have to pay for a knee orthosis provided on January 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a knee orthosis. You say that the patient received a knee immobilizer the day at 
the facility upon discharge to home. You also say that you are not part of the hospital, and are unable to obtain 
pre-authorization at the time of service. The Plan denied your request. The Plan says this provider is not a 
network provider with the Plan, and they have also determined that these services are not urgent or emergent, 
nor were they approved in advance. The Plan also says that both the rendering provider and referring provider 
are non-participating. 
 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 a knee orthosis provided on January 10, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth facility fee provided on January 13, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a telehealth facility fee. You say that the patient is unaware that he needs to 
change his primary care provider (PCP) or that he has a PCP assigned. You also say that the patient only seeks 
care at this facility. The Plan denied your request. The Plan says this provider is not a network provider with 
the Plan, and they have also determined that these services are not urgent or emergent, nor were they approved 
in advance. 
 
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 a telehealth facility fee provided on January 13, 
2022, 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 on December 6, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing with supporting records. 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 that they did not authorize any services for this 
provider or 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 laboratory services provided on December 6, 
2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with power option for the 
enrollee. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no need for the requested wheelchair with the requested power option. 
 The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the enrollee 
does not meet Medicare criteria for the power tilt with power elevating leg rests. The medical records do not 
document that the patient is high risk for development of a pressure ulcer and is unable to perform a functional 
weight shift or that she utilizes intermittent catheterization for bladder management and is unable to 
independently transfer from the wheelchair to bed or the power seating system is needed to manage increased 
tone or spasticity, to qualify for the power tilt feature. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair with power option for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care (99220) provided on November 4, 
2021. 
 
You asked the Plan to pay for the initial observation care. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support the service 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 99220 is initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity.  
 Counseling and/or coordination of care with other physicians, other qualified health care professionals, or 
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. 
Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of high severity. 
Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit.  
 
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 the initial observation care. Our reviewer says that CPT code 
99220 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation 
submitted includes and emergency room evaluation and management procedure.  In this case,  the initial 
observation care procedure code cannot be verified. The services were incorrectly reported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the initial observation care have not been met. Therefore, we decided that the 
Plan does not have to pay for initial observation care (99220) provided on November 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve brake lock extensions and foam tires for a manual 
wheelchair. 
 
You asked the Plan to pre-approve brake lock extensions and foam tires. You say that these components are 
medically necessary. The Plan denied your request. The Plan says the denial of authorization for these 
components is correct, because brake lock extensions and foam tires 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 pre-approve brake lock extensions and foam tires. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee is able to propel the approved wheelchair, and the 
enrollee's upper extremity strength and function appears to be sufficient to use the already approved brakes. The approved wheelchair already comes with tires as part of the wheelchair base. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of brake lock extensions and foam tires have not been met. Therefore, we decided 
that the Plan does not have to pre-approve brake lock extensions and foam tires for a manual wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital care. 
 
You asked the Plan to pre-approve inpatient hospital care. You say that the requested inpatient hospital care is 
medically necessary. The Plan denied your request. The Plan says the requested inpatient hospital care does not 
meet criteria. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
 
 
 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 inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee is undergoing a planned total knee arthroplasty. She is medically stable 
and has been provided medical clearance to undergo this elective procedure. The planned procedure listed 
under CPT code 27447 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an 
ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require 
a greater than 2 midnight stay. The record does not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient hospital care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mobile cardiac outpatient telemetry (MCOT) monitor. 
 You asked the Plan to pre-approve the monitor. You say that you have had many other tests done and none of 
them have been able to explain the reason for your heart problems. The Plan denied your request. The Plan says 
this test is not medically necessary for you; however, a different test has been approved for you. 
 
 
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 monitor. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found you have a history of documented atrial fibrillation and palpitations. Standard ambulatory 
electrocardiogram monitoring would be appropriate and has been approved. As such, guidelines would not 
support a need for MCOT monitoring in this setting. In summary, there is insufficient documentation to support 
the medical necessity for an MCOT monitor in this patients 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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a mobile cardiac outpatient telemetry (MCOT) monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99203) provided July 12, 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 this service is not covered when provided by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
 
 
 
 
 
 The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for physician services (99203) provided July 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to 
the enrollee on September 15, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 pay for the testing. 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 multiple outreach attempts were made to the provider's office 
to verify if they ordered the enrollee to have cardiovascular genetic testing on on before DOS 09/14/2021. Per 
the laboratory's staff, all cardiovascular genetic testing is provided to the enrollee via mail and returned to the 
laboratory via mail. Medicare Part B covers cardiovascular disease screening tests when ordered by the physician who is treating the beneficiary for the purpose of early detection of cardiovascular disease in 
individuals without apparent signs or symptoms of cardiovascular disease. The review indicates that the 
services at issue in this case were not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. The documentation submitted did not 
include a physician order from the treating provider. Based on this information, we decided that Medicare rules 
for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for 
cardiac risk assessment genetic screening testing provided to the enrollee on September 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Carboplatin (J9045), Pembrolizumab (J9271) and 
Paclitaxel (J9267). 
 
You asked the Plan to pre-approve Carboplatin, Pembrolizumab and Paclitaxel. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Carboplatin, Pembrolizumab and 
Paclitaxel. Our reviewer says that the services are not medically necessary. Our physician reviewer found you 
have progression of disease on single agent pembrolizimab. The combination of pembrolizumab with 
carboplatin and paclitaxel would not be considered a standard of care or supported by major drug compendia or 
the medical literature after progression on prior immunotherapy. It is not reasonable or medically necessary and 
unlikely to be safe and effective. 
 
 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Carboplatin, Pembrolizumab and Paclitaxel have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Carboplatin (J9045), Pembrolizumab (J9271) and Paclitaxel 
(J9267).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rhythm electrocardiogram (93042) provided on November 
4, 2021. 
 You asked the Plan to pay for a rhythm electrocardiogram. You say that you have provided records to support 
the level of service. The Plan denied your request. The Plan says rules for payment have not been met because 
the CPT code at issue is inclusive to another 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, we have confirmed that code 93042 
is a column II code to column I code 93010. 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 a rhythm electrocardiogram (93042) provided on November 4, 
2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for hospital observation provided on January 
7, 2022. 
 
You asked the Plan to waive the coinsurance for the hospital observation. You say that the services should be 
covered as you disagree with the charges and your in-network benefits should apply. The Plan denied your 
request. The Plan says the coinsurance applied correctly based on the services provided. 
 
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 50% 
coinsurance for Inpatient hospital care.  
 
 
  You have been asked to pay a 50% coinsurance for the hospital observation (allowed amount is $212.60 x 50% 
= $106.30). The record indicates that these services were performed in an out-of-network facility. 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 coinsurance for hospital observation provided on January 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nerve conduction study provided to the enrollee on June 7, 
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 the denied code remains not supported. 
 
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 95913 is "nerve conduction studies; 13 or more studies." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the documentation does not include 
documentation of nerve conduction studies, and therefore this procedure cannot be verified. A procedure report 
could not be found in the documentation. 
 
We looked at this coder'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 nerve conduction study provided to the enrollee on June 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in your 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nexletol. 
 
You asked the Plan to pre-approve Nexletol. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nexletol.  
 
Benefits for Nexletol may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.