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

 
We decided that the Plan does not have to reimburse you for the non-emergency transportation; wheelchair 
van, provided from April 12, 2021, to September 22, 2021. 
 
You asked the Plan to reimburse you for the transportation services. You say that the enrollee required a 
wheelchair service transportation to and from the hospital for wound care. You also say that all of the enrollee's appointments are for wound care or doctors appointments. The Plan denied your request. The Plan says 
wheelchair van transport is not covered by Medicare. 
 
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. The Plan covers routine transportation when non-ambulance transportation (e.g., by chair car/wheelchair 
van or sedan) through the plan-approved vendor from a hospital to a skilled nursing facility (SNF).  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the file shows that 
you were not transported to a hospital from a skilled nursing facility (SNF). Therefore, we decided that the Plan 
does not have to reimburse you for the non-emergency transportation; wheelchair van, provided from April 12, 
2021, to September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoperative neuromonitoring billed for services 
provided on March 1, 2021. 
 
You asked the Plan to pay for the billed services. You say that the testing was requested by the surgeon. The 
Plan denied your request. The Plan says the billed codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The file shows that pedicle screw testing, electromyography, and train of four testing were billed with CPT 
codes 95907, 95885, and 95999. The billed codes are not supported for the services provided. 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 the intraoperative neuromonitoring billed for services 
provided on March 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the test strips, control solution, and lancets, provided on 
March 20, 2020. 
 
You asked the Plan to pay for the diabetic testing supplies. You say that the items should be covered. The Plan 
denied your request. The Plan says there is no indication of why the enrollee cannot use the Plan's preferred 
brands. 
 
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical 
Equipment (DME) to only those preferred brands and manufacturers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the diabetic testing supplies have not been met. Therefore, we decided that the Plan does not have 
to pay for the test strips, control solution, and lancets, provided on March 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the computed tomography (CT) scan of the heart 
without contrast material, with quantitative evaluation of coronary calcium. 
 
You asked the Plan to pre-approve the CT scan of heart with evaluation of blood vessel calcium. You say that 
this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this service 
is not covered as a standalone test. 
 
The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered 
service and will be denied as not medically necessary. Based on this information, we decided that Medicare 
rules for coverage of the CT scan of heart with evaluation of blood vessel calcium have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the computed tomography (CT) scan of the 
heart without contrast material, with quantitative evaluation of coronary calcium.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 29, 2020, 
to August 1, 2021. 
 
You asked the Plan to pay for the services provided. You say that you are eligible for reimbursement. The Plan 
denied your request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The records provided do not include proof of payment, such as a receipt, 
from the provider. There is also no itemized billing to show what the specific charges are for. The file shows 
that the Plan made multiple attempts to obtain additional information without success.  Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from September 29, 2020, to 
August 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultralightweight wheelchair provided on December 29, 
2021. 
 
You asked the Plan to pay for the provided wheelchair. You say that you are expecting the claims to deny. The 
Plan denied your request. The Plan says the services were not billed with the KX modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We looked at the file and the rules. The rules say that for equipment to be covered, it must be appropriate and 
needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Furthermore, the 
claim does not show that a valid modifier was billed to indicate coverage criteria have been met. Therefore, we 
decided that the Plan does not have to pay for the ultralightweight wheelchair provided on December 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the chest (71260), 
provided on June 27, 2021. 
 
You asked the Plan to pay for the chest CT. You say that the service should be covered. The Plan denied your 
request. The Plan says the records submitted do not indicate that two separate services were 
performed/supported. 
 
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 looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the computed tomography (CT) scan 
of the chest (71260), provided on June 27, 2021. have been met. the records submitted do not indicate that two 
separate services were performed/supported.. Therefore, we decided that the Plan does not have to pay for the 
computed tomography (CT) scan of the chest (71260), provided on June 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter covid-19 test, purchased on January 21, 
2022. 
 
You asked the Plan to pay for the over-the-counter covid-19 test,. You say that the item should be covered. The 
Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan must cover what Medicare covers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the over-the-counter covid-19 test, have not been met. Specifically, this is not a Medicare covered 
item and is not on the over-the-counter list. Therefore, we decided that the Plan does not have to pay for the 
over-the-counter covid-19 test, purchased on January 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection.  
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request is less than the required three months between injections. 
 
The Plan must follow Medicare rules. Medicare rules say that epidural steroid injections are only covered under 
certain medical indications.   
 
We looked at the file and Medicare rules. The records provided do not show that the enrollee has experienced 
at least 50% pain relief for at least three months from the previous injection. 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 an epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen concentrator (), purchased on January 
21, 2022. 
 
You asked the Plan to pay for the portable oxygen concentrator. You say that the item should be covered. The 
Plan denied your request. The Plan says oxygen equipment is only covered if rented. 
 
The Plan must follow Medicare rules. Medicare rules say that for oxygen and oxygen equipment, contractors 
pay a monthly fee schedule amount per beneficiary. Unless otherwise noted below, the fee covers equipment, 
contents and supplies. Payment is not made for purchases of this type of equipment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the portable oxygen concentrator have not been met. Specifically, you purchased the equipment, and therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for the portable 
oxygen concentrator (), purchased on January 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on December 23, 2021. 
 
You asked the Plan to pay for the testing services. You say that the services were deemed medically necessary. 
The Plan denied your request. The Plan says one code must be submitted for the panel. 
 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 looked at the file and the rules. If a single procedure is performed, only one code with one unit of service 
may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage of 
the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the panel 
testing provided on December 23, 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gradient segmental appliance (E0673), provided on July 
30, 2021. 
 
You asked the Plan to pay for intermittent limb compression device. You say that the item should be covered. 
The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for 
the prevention of deep vein thrombosis during or after surgery in a hospital setting. 
 The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file shows that this item was used for the prevention of deep vein thrombosis in a hospital setting. 
Therefore, we decided that the Plan does not have to pay for the gradient segmental appliance (E0673), 
provided on July 30, 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 there is no need for physician supervision 3 times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the 
current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy. 
Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per 
day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented 
acute nursing needs. While you may benefit from physical therapy and occupational therapy, the rehabilitation 
needs can be safely met in an alternate and lower intensity setting. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on 
September 28, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the DME. You say that the items should be covered. The Plan denied your 
request. The Plan says prior authorization must be obtained for out0of0network services. 
 
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 the durable medical equipment (DME) provided 
on September 28, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromonitoring services provided on January 6, 2022. 
 
You asked the Plan to pay for the services provided. You say that the monitoring helps protect the enrollee 
from neurological insults. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
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 95938 is short-latency somatosensory evoked potential 
study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper 
and lower limbs.  
 
 
 We find that CPT code 95938 is not supported in the medical record. Specifically, there is a more 
comprehensive code available to describe the somatosensory evoked potential studies provided in the upper 
extremities. 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 neuromonitoring services 
provided on January 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tagrisso 80 mg tablet. 
 
You asked the Plan to pre-approve Tagrisso. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
benefit. 
 
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 Tagrisso 80 mg tablet.  
 Benefits for Tagrisso may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on July 29, 2021. 
 
You asked the Plan to pay for the testing services. You say that the services were deemed medically necessary. 
The Plan denied your request. The Plan says the testing is considered unproven. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation.  
 The file shows that urinary tract infection (UTI) panel testing was provided. We looked at the file and Medicare 
rules. In this case, there are insufficient medical records to show that the testing was necessary over the 
standard of care. Therefore, we decided that the Plan does not have to pay for the panel testing provided on 
July 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Ultrasound (76642-26-LT and 76642-26-RT) provided 
on January 27, 2022. 
 You asked the Plan to pay for codes 76642-26-LT and 76642-26-RT. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76642 is 2. The MAI value for this code is 2. You billed 4 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of codes 
76642-26-LT and 76642-26-RT have not been met. Therefore, we decided that the Plan does not have to pay 
for the Ultrasound (76642-26-LT and 76642-26-RT) provided on January 27, 2022.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 there is no need for physician supervision 3 times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the 
current level of function, the enrollee does not require an intensive, complex, multidisciplinary approach to 
daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of 
therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no 
documented acute nursing needs. While the enrollee may benefit from physical therapy and occupational 
therapy, the rehabilitation needs can be safely met in an alternate and lower intensity setting. 
 
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.