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

 
We decided that the Plan does not have to pre-approve attendant control (E2331) and a power seat elevation 
system (E2300) for the enrollee. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says the items are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an attendant control is covered in place of a 
beneficiary-operated drive control system if the beneficiary meets coverage criteria for a wheelchair, is unable 
to operate a manual or power wheelchair and has a caregiver who is unable to operate a manual wheelchair but 
is able to operate a power wheelchair. Medicare rules also say that for equipment to be covered, it must 
primarily serve a medical purpose. 
 
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 items. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the applicable rules say that an attendant control is covered in place of a beneficiary-operated drive 
control system if the beneficiary meets coverage criteria for a wheelchair, is unable to operate a manual or 
power wheelchair and has a caregiver who is unable to operate a manual wheelchair but is able to operate a 
power wheelchair. The documentation indicates that the patient can operate the power wheelchair safely. 
 
We looked at this physician's review, the file, and Medicare rules. Our reviewer found that the attendant control 
is not reasonable in this case. Additionally, the power seat elevation system is not primarily medical in nature, 
and is never covered. Based on this information, we decided that Medicare rules for coverage of the items have 
not been met. Therefore, we decided that the Plan does not have to pre-approve attendant control (E2331) and a 
power seat elevation system (E2300) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for administration of Prolia (J0897, 96372) 
provided on December 6, 2021. 
 
You asked the Plan to waive the coinsurance for administration of Prolia. You say that you were told by a 
representative of the Plan that the Plan would pay everything except $5. The Plan denied your request. The 
Plan says the correct coinsurance was applied. 
 
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 20% 
coinsurance for administration of drugs at a specialist's office.  
 
You have been asked to pay $257.01, or 20% of the Medicare-allowed charge of $1,285.04, for administration 
of Prolia. Administration of Prolia falls within the "Medicare Part B prescription drugs" 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 coinsurance for administration of Prolia (J0897, 96372) provided on 
December 6, 2021.  Your complaint about receiving erroneous or incomplete information about your cost-sharing responsibility 
from a representative of the Plan is not a valid appeal for medical coverage. This part of your complaint is a 
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types 
of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry rendered on September 22, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 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 83789 
is a column II code to column I code G0480. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 mass spectrometry rendered on September 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the technical component (TC) of the surgical pathology 
services provided on April 1, 2021. 
 
You asked the Plan to pay for the TC of the pathology services. You say that this should be paid as billed. The 
Plan denied your request. The Plan says only the professional component of code 88305 is payable. This must 
be billed with modifier -26. 
 
The Plan must follow Medicare rules. Medicare rules say that payment is not made under the physician fee 
schedule for TC services furnished in institutional settings where the TC service is bundled into the facility 
payment, e.g., hospital inpatient and outpatient settings.  We looked at the file and Medicare rules. The global code for 88305 was billed which includes both the 
professional and TC. Only the professional component is payable since the services were provided to a hospital 
outpatient. Based on this information, we decided that Medicare rules for coverage of the TC of the pathology 
services have not been met. Therefore, we decided that the Plan does not have to pay for the technical 
component (TC) of the surgical pathology services provided on April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office provided on August 23, 2021  You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing 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 $35 for Physician/Practitioner services, including doctor's office visits.       You have been asked to pay a $35 for a specialist office visit. Specialist office visits fall within the Physician/Practitioner services, including doctor's office visits 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 specialist office provided on August 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation. 
 
You asked the Plan to pre-approve additional miles. You say that you have a checkup with your doctor. The 
Plan denied your request. The Plan says the mileage is over your allowed benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 
 
 Routine transportation over 50 miles was requested. We looked at your request, the records in the case file, and 
the rules. Your plan only covers transportation for up to 50 miles. Based on this information, we decided that 
the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional mileage for routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve RFA to the SI joint. You say that this procedure is medically necessary for 
your condition. The Plan denied your request. The Plan says medical studies have not proven that this service is 
helpful for the treatment of your problem. 
 
The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation used for sacro-iliac joint 
pain is considered not medically necessary/investigational whether performed using traditional, cooled, or 
pulsed radiofrequency. Based on this information, we decided that Medicare rules for coverage of RFA to the 
SI joint have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency 
ablation (RFA) to the sacroiliac (SI) joint.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve treatment with Capecitabine (J8521). 
 
You asked the Plan to pre-approve Capecitabine. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that medical necessity rules for use of the requested drug 
have not been met because the use at issue is off-label and not medically supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Capecitabine. Our reviewer says that 
the requested drug is medically reasonable and necessary in this case. Our physician reviewer found that the 
requested use of Capecitabine is not FDA-approved for the enrollees diagnosis. However, the use us supported 
by one of the major drug compendia. The documentation supports that the requested drug is safe and effective 
and otherwise reasonable and necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Capecitabine have been met. Therefore, we decided that the Plan has to pre-
approve treatment with Capecitabine (J8521).  
 
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 a pneumatic compression device (E0675) and segmental 
pneumatic appliance (E0673). 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that these services are 
not paid to you by the facility and payment for items used should not be included with payment to the facility, 
as you bill charges separately for services provided under a DME license. The Plan denied your request. The 
Plan says payment is not allowed for DME when billed with a place of service other than what CMS allows. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say 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) and segmental pneumatic appliance (E0673).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, 40 to 54 minutes (99215), and prolonged 
office visit beyond minimum requires time (99417) provided on December 7, 2021. 
 
You asked the Plan to pay for the naturopathy services. You say that it is a financial burden to pay this charge. 
The Plan denied your request. The Plan says the claim denied correctly. 
 
Medicare generally does not cover naturopathy services. However, the Plan offers a naturopathy benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a naturopathy benefit in excess of Medicare coverage, the frequency limit of 6 visits per 
calendar year has been exceeded. The record shows that the Plan paid for naturopathy services you received on 
January 4, 2021, March 3, 2021, April 20, 2021, June 23, 2021, August 11, 2021, and September 22, 2021. 
Therefore, we decided that the Plan does not have to pay for the office visit, 40 to 54 minutes (99215), and 
prolonged office visit beyond minimum requires time (99417) provided on December 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. 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 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 documentation does not support the necessity for admission to an IRF.  While you may benefit from physical therapy and occupational therapy, at your current functional level, your 
rehabilitation needs can be addressed at a low intensity alternate setting such as in an skilled nursing facility or 
in-home with services. 
 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (CPT code 01220) provided on November 5, 
2021. 
 
You asked the Plan to pay for the anesthesia. You say that the claim should be paid. The Plan denied your 
request. The Plan says the submitted medical records do not support that anesthesia for all closed procedures 
involving upper two-thirds of femur was performed. 
 
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 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 anesthesia. Our reviewer found the review indicates that 
CPT code 01220 QZ P3 (180 units) remains not supported. The submitted medical records do not support that 
anesthesia for all closed procedures involving upper two-thirds of femur was performed. Therefore, the billed 
CPT code, modifiers and units cannot be verified. Of note, there is a more appropriate CPT) code (01230) for 
open procedures that should be billed. It is noted that multiple attempts were made to contact the provider for 
additional information. The review has determined that the service was not supported by the medical records 
provided.  
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 anesthesia have not been met. Therefore, we decided that the Plan does not 
have to pay for the anesthesia (CPT code 01220) provided on November 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter insertion or replacement of permanent 
leadless pacemaker, right ventricular, including imaging guidance and device evaluation when performed 
(33274). 
 
You asked the Plan to pre-approve a leadless pacemaker. You say that you are requesting reconsideration of the 
denied services. The Plan denied your request. The Plan says the enrollee would need to have clinical notes that 
show the enrollee is going or is going to be enrolled and participating in a CMS approved CED study. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a leadless pacemaker have not been met. Specifically, there is no evidence of the enrollee being in 
an approved CED study for a leadless pacemaker. Therefore, we decided that the Plan does not have to pre-
approve a transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular, including 
imaging guidance and device evaluation when performed (33274).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department services (99283) provided on 
January 4, 2022. 
 
You asked the Plan to pay for the emergency department services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim is bundled to 
another service billed on the same day by the same provider. 
 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 99283 
is a column II code to column I code 99284. 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 the emergency department services (99283) provided on January 
4, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care services. 
 
You asked the Plan to pre-approve the requested services. You say that daily living skills are getting difficult 
for the enrollee. The Plan denied your request. The Plan says the request is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. We find that the services at issue in this case are considered custodial 
in nature. Based on this information, we decided that Medicare rules for coverage of the requested services 
have not been met. Therefore, we decided that the Plan does not have to pre-approve personal care services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation. 
 
You asked the Plan to pre-approve routine transportation. You say that you need transportation. The Plan 
denied your request. The Plan says the requested service is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of routine transportation have not been met. Specifically, you must be 
referred by a Plan advocate and use the Plan approved transportation service in order to receive non-emergency 
transportation. Therefore, we decided that the Plan does not have to pre-approve routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visits. You say that it is necessary to receive medical care for your 
cancer from an OON provider. The Plan denied your request. The Plan says there are multiple in-network 
options available for second opinion services regarding your medical condition. 
 
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 
office visits to be provided by an out-of-network (OON) provider.