Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy sessions for the enrollee. 
 
You asked the Plan to pre-approve the sessions. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is nothing in the supplied documentation that supports that the services will be of 
such a level of complexity and sophistication, or the condition of the patient will be such that the services 
required can be safely and effectively performed only by a qualified therapist or under a therapist's supervision, 
versus a home exercise program after the total approved visits. 
 
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 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 that a physical therapy note dated 7/27/2022 indicated that the patient 
is walking two miles before taking a break to sit. There is no documentation indicating that the patient has 
significant functional deficits that impair his mobility or ability to perform daily activities. The patient may still 
require increasing his endurance and strength, but this is not complex enough to require the services of a skilled 
physical therapist and can be accomplished with an independent exercise program. 
 
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 sessions have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional physical therapy sessions for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray provided on March 11, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for x-ray. You say that you are appealing the claim payment denial. The Plan denied 
your request. The Plan says the services were provided out-of-network and were not approved in advanced. 
 
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 x-ray provided on March 11, 2022, by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Ultra test strips (A4253). 
 
You asked the Plan to pre-approve test strips. You say that the requested test strips are necessary. The Plan 
denied your request. The Plan says the medical information received shows that you have not tried a preferred 
blood glucose test strip or have a reason why an exception should be made for using a non-preferred glucose 
test strip. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician or treating practitioner must 
document in the beneficiarys medical record the reason why the specific brand or mode of delivery is 
necessary to avoid an adverse medical outcome. We looked at the file and Medicare rules. The file does not include any documentation from your physician 
documenting why you require this specific brand of test strips. Without this, medical necessity cannot be 
established. Based on this information, we decided that Medicare rules for coverage of test strips have not been 
met. Therefore, we decided that the Plan does not have to pre-approve OneTouch Ultra test strips (A4253).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional transportation. The Plan denied your request. The Plan says you 
have used 24 one-way trips, and have no trips remaining for 2022. The Plan also says this request exceeds the 
benefit limits set in the subscriber agreement for routine transportation. 
 
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 a maximum of up to 24 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93042 and 99053 billed for date of service 
October 6, 2021. 
 
You asked the Plan to pay for procedure codes 93042 and 99053. You say that the correct codes were assigned, 
and no coding changes are required. You say that the services were medically necessary, and the attached 
medical records support the claim as originally billed. The Plan denied your request. The Plan says payment for 
code 93042 is bundled into payment for code 93010. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93042 
is a column II code to column I code 93010. Procedure code 93042 has not been billed with an appropriate 
modifier to bypass the edit. 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 the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 93042 and 99053 billed for date of service October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epifix.  
You asked the Plan to pre-approve Epifix. You say that the enrollee needs immediate closure of a pressure 
ulcer with Epifix allograft. The Plan denied your request. The Plan says the request is not medically necessary 
because the records show that the enrollee's wounds involve tendon and muscle. The Plan says that the 
enrollee's left hip wound has infected and has dead tissue. The Plan says that the records do not document 
failure of the enrollee's wound to improve in a 4-week period. 
 
The Plan follows Medicare rules. Medicare rules say that the application of CTPS to Ulcers or Wounds is only 
covered when there is evidence of a Failed Response. 
 
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 Epifix. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has chronic pressure ulcers 
on her sacrum and left hip. The record sent by the provider indicates that on September 12 and September 19, 
2022, the sacral wound measured 7 x 3.5 centimeters (cm), and the left hip wound measured 5 x 5 cm. The 
sacral wound involved the epidermis, dermis, subcutaneous tissue, muscle and tendon down to bone. It has 
healthy granulation tissue. The left hip wound had a dense full-thickness eschar (dead tissue) involving the 
epidermis, dermis, subcutaneous tissue, muscle and tendon down to bone. The wound was purulent (infected) 
and necrotic. The records do not document evidence of failed healing by contraction and advancement of 
epithelial margins following 4 weeks of optimization. There is no Failed Response to current treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Epifix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Epifix.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an expandable controller (E2377), an electrical connection 
between wheelchair controller and two more motors (E2311) and a harness (E2313). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested accessories are both 
medically needed and justified, as per Medicare Article A52504 and Medicare's approval. The Plan denied your 
request. The Plan says that the enrollee does not have a medical need for a group 3 power wheelchair with the 
requested power option(s)/feature(s)/accessories. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 wheelchair accessories. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a past medical history of MS with spasticity and tetraparesis. Clinical 
documentation shows that the enrollee has significant spasticity with limited ROM of upper limbs with pain 
thus, the requested accessories are all medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have been met. Therefore, we decided that the Plan has 
to pre-approve an expandable controller (E2377), an electrical connection between wheelchair controller and 
two more motors (E2311) and a harness (E2313).  
 
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: 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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the records do not show that you are able to tolerate the intensity 
of an IRF or that there is an expectation to significantly improve in a reasonable amount of time. The Plan says 
that the services needed can be safely provided in another setting. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical repair of a hip fracture after a fall. Your medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. There is not a reasonable 
expectation that you 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: 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 you are appealing with supporting records. The Plan 
denied your request. The Plan says based on Medicare guidelines, the IRF services being requested do not meet 
the requirements for approval. 
 
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 patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. Our physician reviewer also 
found that while the medical record supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Our physician reviewer also found that medically 
necessary care can be provided in a different level of 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional 
routine transportation. The Plan denied your request. The Plan says the benefit for routine transportation has 
been exhausted. 
 
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 a maximum of 60 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an external upper limb tremor stimulator provided on April 
28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an external upper limb tremor stimulator. You say that the item provided was 
medically necessary. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 an external upper limb tremor stimulator provided 
on April 28, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external transmitter provided on March 30, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim 
exceeds the medically unlikely edit. 
 
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 L8683 is radiofrequency transmitter (external) for use 
with implantable neurostimulator radiofrequency receiver.  
 The file shows that 1 unit of CPT code L8683 was previously billed and paid by the Plan. We find that 2 
additional units of CPT code L8683 is not supported in the medical record. 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 external transmitter provided on March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93042 and 99053 billed for date of service 
October 23, 2021. 
 
  You asked the Plan to pay for procedure codes 93042 and 99053. The Plan denied your request. The Plan says 
procedure codes 99291 and 93010 have been paid. The Plan also says procedure code 93042 is inclusive to 
procedure code 99291 and procedure code 99053 is 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 93042 
is a column II code to column I code 99291 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 93042 
and 99053 billed for date of service October 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 tests purchased on December 29, 
2021, and January 17, 2022. 
 
You asked the Plan to pay for the at-home COVID-19 tests. You say that you were advised by a representative 
to submit for reimbursement, and nothing was mentioned about dates. The Plan denied your request. The Plan 
says these tests were not covered at the time you purchased them. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
COVID-19 tests are an OTC item. The 2022 Evidence of Coverage clearly states that coverage applies to 
eligible at-home COVID-19 tests that are purchased on or after February 1, 2022, and the tests you bought 
were purchased before February 1, 2022. Therefore, we decided that the Plan does not have to pay for the at-
home COVID-19 tests purchased on December 29, 2021, and January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breathing capability test coded 94010 and the 
plethysmography services coded 94726 provided on March 1, 2022. 
 
You asked the Plan to pay for the breathing capability test and the plethysmography 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 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 codes 94010 and 94726 are not supported in the medical record. Specifically, these codes 
have a professional component/technical component of 1. This claim was billed with place of service 21 
(inpatient hospital). The professional interpretation was furnished in the same payment locality from where the 
technical component was furnished. We find that the Medicare rule for payment of this claim has not been met as the professional interpretation of a diagnostic test must be separately billed with modifier  26 by the 
interpreting physician. Based on this information, we decided that Medicare rules for coverage of the breathing 
capability test and the plethysmography services have not been met. Therefore, we decided that the Plan does 
not have to pay for the breathing capability test coded 94010 and the plethysmography services coded 94726 
provided on March 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that information received shows that the enrollee has medical 
conditions that need to be evaluated and monitored further by his current doctors. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where he/she is 
currently receiving care. All medically necessary care is being provided in the current acute care setting. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.