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

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2377) for the enrollee. 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee's upper limb strength and function are adequate for the member to be 
able to control the power options using their own switches which are included in the allowance of these power 
options. 
 
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 accessories. Our reviewer says that 
the requested accessories are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the patient does not require a ventilator, or non-proportional input devices (e.g., sip and 
puff, head array, etc.). The patient does not require a separate display (i.e., for alternate control devices), other 
electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control), or an attendant control. The patient has power options on the wheelchair, but the patient does not need 
to control the power options through a joystick. The patient's upper extremity strength supports that the patient 
can control any power options through their own switches.  
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care for the enrollee. 
 
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee does not require skilled nursing care. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. There 
is no documentation that the patient requires skilled nursing services. The patient does require skilled therapy 
services. There is no documentation that daily skilled services are required. Although records document the 
patient is very limited functionally, provided records do not document the patient has the ability to cooperate 
with therapy and follow commands to necessitate daily inpatient skilled therapy services. There is no 
documentation that the patient requires the services on an inpatient basis, only in a skilled nursing facility 
setting. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 
care. 
 
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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 2, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 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 81413 is a column II code to column I code 81439 with a modifier 
indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing 
criteria have not been met. 
 
Cardiovascular risk assessment panels are only covered for certain indications. While cardiovascular risk 
assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for 
these services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on 
March 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated knee brace. 
 
You asked the Plan to pre-approve the knee brace. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a custom fabricated knee orthosis is covered for the 
indications established in the applicable LCD. 
 
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 knee brace. Our reviewer says that 
the requested knee brace is not medically reasonable and necessary. Our physician reviewer found that the 
documentation does not reveal knee instability documented with an objective description of joint laxity or 
instability (e.g., varus/valgus instability, anterior/posterior Drawer test). There is no evidence of recent injury 
or surgery to the knee. The enrollee is documented to be ambulatory, however, the criteria for the requested 
knee orthosis has not been met. 
 
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 knee brace have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a custom fabricated knee brace.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service February 28, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99053 is considered bundled and 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 procedure code. 
 We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service February 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services coded 99291 provided on April 29, 
2022. 
 
You asked the Plan to pay for the critical care services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, this service was provided on 
the same date of service as a minor surgery (code 36556). This means this service is included in the global 
package of the surgery procedure. This code is not separately payable as billed. Based on this information, we 
decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided 
that the Plan does not have to pay for the critical care services coded 99291 provided on April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92014) 
provided on May 27, 2022. 
 
You asked the Plan to waive the copayment for a medical eye examination. You say that you should not have a 
co-payment for the service. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 Medicare covered vision services.  
 
You have been asked to pay a $40 copayment for a medical eye examination. This item/service falls within the 
Medicare covered vision 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 a 
medical eye examination (92014) provided on May 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve all lower extremity prostheses, flex-walk system or 
equal (L5981) and all lower extremity prostheses, multi-axial rotation unit ('MCP' or equal) (L5986). 
 
You asked the Plan to pre-approve the K3 Foot and ankle. You say that the purpose of the new foot is to 
eliminate the shock absorber and rotation feature on the current L5987 high end foot. The Plan denied your 
request. The Plan says the requested K3 foot and ankle does not meet Medicare criteria as reasonable and 
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 the K3 Foot and ankle. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the K3 Foot and ankle are not medically necessary per Local Coverage 
Determination (LCD) Lower Limb Prostheses L33787. The documentation reveals that the enrollee was 
approved for a manual wheelchair due to multiple falls. The physician documentation does not support that this 
enrollee's level with history of multiple falls is a K3 ambulator. 
 
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 K3 Foot and ankle have not been met. Therefore, we decided that the Plan 
does not have to pre-approve all lower extremity prostheses, flex-walk system or equal (L5981) and all lower 
extremity prostheses, multi-axial rotation unit ('MCP' or equal) (L5986).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed for code 83789 for date of service 
March 17, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service was medically necessary and should be 
paid. The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for validity testing billed for code 83789 for date of service March 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on February 11, 2022. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says targeted genomic sequence analysis panel, code 81455, is a non-covered code. 
Genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in 
the clinical management of the enrollee and will be denied automatically as not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the code reported, 81455, is a non-
covered code for Medicare purposes. Based on this information, we decided that Medicare rules for coverage 
of these services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
provided to the enrollee on February 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical procedure (97597) provided on January 17, 
2022. 
 
You asked the Plan to pay for procedure code 97597. 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 the Medicare approved amount for global 
surgery procedures includes payment for the above services related to the surgery when furnished by the 
physician who performs the surgery.  
We looked at the file and Medicare rules. The surgical procedure in question (code 97597) was provided within 
the 10-day global period for the surgical procedure (code 36589) that was provided on January 11, 2022. This 
means that payment for code 97597 was included in the payment for code 36589. Code 97597 was not billed 
with the appropriate modifier indicating that the service was unrelated and rendered during the postoperative 
period of the global procedure. Therefore, we decided that the Plan does not have to pay for the surgical 
procedure (97597) provided on January 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical procedure (15100) provided on May 20, 2022. 
 
You asked the Plan to pay for procedure code 15100. 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 the Medicare approved amount for global 
surgery procedures includes payment for the above services related to the surgery when furnished by the 
physician who performs the surgery. 
 
We looked at the file and Medicare rules. The surgical procedure in question (code 15100) was provided within 
the 90-day global period for the surgical procedure (code 14000) that was provided on May 2, 2022. This 
means that payment for code 15100 was included in the payment for code 14000. Code 15100 was not billed 
with the appropriate modifier indicating that the service was unrelated and rendered during the postoperative 
period of the global procedure. Therefore, we decided that the Plan does not have to pay for the surgical 
procedure (15100) provided on May 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 7, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization 
is required prior to an out-of-network visit. 
 
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 home health services provided on March 7, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on February 25, 2022. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare guidelines state 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. The claim did not include all the documentation to process the claim. The required DEX 
Z-Code was not provided. Additionally, the claim was billed with a date of service inconsistent with Medicare 
rules governing laboratory services. The specimen was collected on January 13, 2022, rather than the billed 
date of service February 25, 2022. There is no documentation to support genetic testing on the billed date of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due 
to the omission of a require code and inconsistency with the dates of service.  Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services provided to the enrollee on February 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair with power tilt and seat 
cushion. 
 
You asked the Plan to pre-approve the wheelchair and accessories. The Plan denied your request. The Plan says 
the coverage criteria are not met. 
 
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 and accessories. Our 
reviewer says that the requested group 2 power wheelchair and accessories are not medically reasonable and 
necessary. Our physician reviewer found that although the provided medical records report weakness and 
unstable gait, there is no specific documentation that this enrollee has a personal mobility deficit that impairs 
participation in mobility-related activities of daily living such as toileting, feeding, grooming, and bathing in 
customary locations within the home. Based on the medical records provided there is no documentation that the enrollee's mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair. The provided 
records recommend a walker for mobility. There is no documentation that the enrollee can safely operate a 
power mobility device. 
 
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 and accessories have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a group 2 power wheelchair with power tilt and seat cushion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) provided on May 25, 2022. 
 
You asked the Plan to pay for an eye refraction. You say that the service was necessary and should be covered. 
The Plan denied your request. The Plan says the service at issue is not a covered benefit when performed 
during a medical eye examination.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when it is performed as part of a routine screening by a participating 
provider. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of an eye refraction have not been met. Specifically, eye refraction is only covered by the Plan when 
it is performed as part of a routine screening by a participating provider. This service was performed for 
medical vision purposes, and therefore is not a covered benefit. Therefore, we decided that the Plan does not 
have to pay for an eye refraction (92015) provided on May 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable drug delivery system provided from 
December 14, 2021, to December 20, 2021. 
 
You asked the Plan to pay for the disposable drug delivery system. The Plan denied your request. The Plan says 
this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including 
elastomeric infusion pumps (A4305, A4306, A9274) are non-covered devices because they do not meet the 
Medicare definition of durable medical equipment.  
 
We looked at the file and Medicare rules. Per LCA A52507, the requested disposable drug delivery system is 
not covered. Based on this information, we decided that Medicare rules for coverage of the disposable drug 
delivery system have not been met. Therefore, we decided that the Plan does not have to pay for the disposable 
drug delivery system provided from December 14, 2021, to December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on February 23, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with inappropriate diagnosis codes. 
 
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the 
condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the 
medical record, assign the code for the unspecified side.  
 
We looked at the file and Medicare rules. In this case, it is inappropriate to bill a diagnosis code that specifies 
laterality (C50.911) with a diagnosis code that indicates unspecified laterality (C50.919). 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 the services provided on February 23, 2022.