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) sessions. 
 
You asked the Plan to pre-approve the additional PT sessions. The Plan denied your request. The Plan says the 
additional visits are not medically necessary. The Plan also says that there is a lack of documentation to support 
the need for a skilled 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 the additional PT sessions. 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 additional requested therapy generally is not 
accepted as specific and effective therapy for the patients condition beyond what was approved by the Plan. 
Our reviewer found that the patient has had prior therapy and the documentation does not reveal that the patient 
requires the unique skills of a professional therapist to safely and effectively provide treatment, or that the 
services can be safely and effectively performed only by a therapist, or by or under the supervision of a 
therapist. The patient is compliant in a home exercise program. Our physician reviewer also found that the 
requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of 
a qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's 
current condition or to prevent or slow further deterioration. 
 
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 additional PT sessions have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 10 additional physical therapy (PT) sessions.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Tempus gene panel (81206, 81235, 81321) provided on 
June 28, 2021. 
 
You asked the Plan to pay for a Tempus gene panel. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  To report a Comprehensive Genomic Profile 
(CGP) service, test providers should use CPT code 81479 at this time 
 We find that CPT codes 81206, 81235, and 81321 are not supported in the medical record. Specifically, these 
codes were used to report a CGP service, which should be reported with 81479. Based on this information, we 
decided that Medicare rules for coverage of a Tempus gene panel have not been met. Therefore, we decided 
that the Plan does not have to pay for a Tempus gene panel (81206, 81235, 81321) provided on June 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 8, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the lab tests 
are the responsibility of the dialysis center. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on June 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence of the necessary pain-free range of motion in the upper extremities 
necessary to operate the tiller steering mechanism. 
 
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 scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found you have a personal 
mobility deficit but the documentation does not support that it impairs participation in MRADLs in the home. 
Your mobility deficit could be helped in the home with a four-wheeled walker. The documentation does not 
reveal that you have the pain free range of motion in the upper extremities to operate a tiller.  
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Parkinson-Alzheimer-Dementia Panel provided on June 
1, 2021. 
 
You asked the Plan to pay for the Parkinson-Alzheimer-Dementia Panel. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was not 
billed with the correct POS code. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the Parkinson-Alzheimer-Dementia Panel have not been met. Specifically, this claim was billed 
with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. 
Therefore, we decided that the Plan does not have to pay for the Parkinson-Alzheimer-Dementia Panel 
provided on June 1, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health telehealth visit provided on 
April 26, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the telehealth visit. You say that this provider did not provide backup 
documentation to your plan, so you would like to appeal. The Plan denied your request. The Plan says 
unauthorized, non-plan care is not covered. 
 
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 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 outpatient mental health telehealth visit 
provided on April 26, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cold cap provided on September 29, 2021. 
 
You asked the Plan to pay for the provided services. You say that the cap is made of very durable material. The 
Plan denied your request. The Plan says the cap does not meet the definition of durable medical equipment. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the cold cap provided on September 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve Opdivo. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements for coverage because he 
experienced disease progression while being treated with Imfinzi. 
 
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 Opdivo. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the requested use of Opdivo is not FDA-
approved for the enrollee's diagnosis. The enrollee is on immunotherapy with progression. The use of Opdivo 
is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved 
medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have any parental 
medication; complex wound care or nutrition given via a feeding tube. She is medically stable without any 
acute exacerbations of chronic medical problems. Her physical function is at or near her baseline. Although 
further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled 
services can be provided at a lower level of care than a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit you had with a chiropractor on October 20, 
2021. 
 
You asked the Plan to pay for the chiropractic office visit. You say that you were told that if the chiropractor 
did a spinal manipulation, that it would be covered. The Plan denied your request. The Plan says office visits 
with a chiropractor are not covered under any condition. Only manual manipulation of the spine is covered by a 
chiropractor. The Plan says that it has paid for the manual manipulation of the spine you had on this date of 
service, but not the office visit itself. 
 
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 the office visit you had with a chiropractor on October 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a functional electrical stimulator and supplies. 
 
You asked the Plan to pre-approve a functional electrical stimulator and supplies. You say that this is medically 
necessary. The Plan denied your request. The Plan says that the denial of functional electrical stimulator and 
electrical stimulator supplies was appropriate given the clinical scenario and the guidance presented. 
 
The Plan must follow Medicare rules. Medicare rules say that a functional electrical stimulator is covered if 
Medicare criteria have been met. 
 
We looked at the file and Medicare rules. The file does not indicate you are using this to treat muscle atrophy 
where nerve supply to the muscle is intact or being used to help walking because of a spinal cord injury. Based 
on this information, we decided that Medicare rules for coverage of a functional electrical stimulator and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a functional 
electrical stimulator and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids you purchased from an out-of-network provider 
on November 8, 2021. 
 
You asked the Plan to pay for the out-of-network hearing aids. You say that you were not aware that a network 
provider had to be used for this benefit. The Plan denied your request. The Plan says hearing aids purchased 
from an out-of-network provider are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the Plan's network hearing aid vendor.  
 
Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. 
Therefore, we decided that the Plan does not have to pay for hearing aids you purchased from an out-of-
network provider on November 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the head. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no records showing a diagnosis of dementia. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the record indicates that 
the enrollee has memory loss related to medication in 2016.  The record does not indicate recent trauma. The 
record indicates a normal neurologic examination with no evidence of dementia given a MMSE of 28/30. The 
provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the 
requested service. The elements of the coverage criteria are not satisfied. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) scan of the head.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82310, 82727, 83540, 83550 and 
84100) provided on October 11, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the provider reported routine lab services 
related to the treatment of end stage renal disease (ESRD), which does not follow industry standard coding 
rules. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services (82310, 82727, 83540, 83550 and 84100) provided on October 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance transportation (A0428) and 
ground mileage (A0425) provided on October 9, 2021. 
 
You asked the Plan to pay for the non-emergent ambulance transportation and ground mileage. You say that 
this was a medically necessary and reasonable transport, and should be covered. The Plan denied your request. 
The Plan says the criteria for medical necessity are not met. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergent ambulance transportation 
and ground mileage. Our reviewer says that the ambulance transport on October 9, 2021 was not medically 
reasonable and necessary for the patient. Our physician reviewer found that the documentation did not support 
that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) 
were contraindicated for this patient. Our reviewer also found that the documentation did not support that the 
patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped 
ambulance can provide for safe transport on October 9, 2021.  
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 non-emergent ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transportation 
(A0428) and ground mileage (A0425) provided on October 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on March 23, 
2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you were transferred to rehab 
six miles away from the hospital, the hospital did not give you an option to get to the care facility by yourself. 
You also say that nobody explained to you about the copayment for ambulance services. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $250 
copayment for ground ambulance services.  
 
You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the 
Ambulance Services 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 ambulance services 
provided on March 23, 2021.  
 
Your complaint about the hospital not giving you the option to transport yourself and nobody explaining the 
copayment for ambulance services 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 drug testing services provided on June 1, 2021. You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed codes 
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. In this case, the claim 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 testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for the drug testing services provided on June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99203) provided on 
September 1, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $40 copayment for services obtained from a 
specialist, or under certain circumstances, treatment by a nurse practitioner or physicians assistant or other 
non-physician health care professionals in a specialists office. Additionally, your in-network maximum out-of-
pocket amount is $3,900 for the year 2021. This is the most you pay during the calendar year for covered 
Medicare Part A and Part B services received from network providers. 
 
You have been asked to pay a $40 copayment for the specialist office visit provided as you had not previously 
met your in-network maximum out-of-pocket expense for the calendar year at the time of service. 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 the office visit (99203) provided on September 1, 2021.