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

 
We decided that the Plan does not have to pay for the non-covered ambulance mileage (A0888) provided on 
May 31, 2021. 
 
You asked the Plan to pay for the non-covered ambulance mileage. You say that you requested to be 
transported to a specific hospital because it was closer to your home. You also say you feel you should not have 
to pay for the ambulance ride that you told the hospital staff you did not want. The Plan denied your request. 
The Plan says the non-covered ambulance mileage does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The Medicare rules say that miles beyond the closest available facility 
cannot be billed to Medicare.  
 
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-covered ambulance mileage. Our 
reviewer says that the non-covered ambulance mileage does not meet the criteria for coverage. Our physician 
reviewer found you were evaluated and found to have multiple rib fractures requiring care in a facility with 
trauma services. There was a facility with trauma services located closer to the treating facility, which could 
have accepted you, but you requested transport to a facility that was further from the treating facility. Our 
reviewer also found that the documentation does support that you could have been treated at a closer facility, as 
opposed to the one you requested to be transported to. 
 
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-covered ambulance mileage have not been met. Therefore, we decided 
that the Plan does not have to pay for the non-covered ambulance mileage (A0888) provided on May 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ofev 100MG capsule. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says Ofev is a self-administered drug and does not fall under Part B 
coverage. 
 
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 Ofev 100MG capsule.   
Benefits for the medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99358 billed for date of service May 9, 2022. 
 
You asked the Plan to pay for procedure code 99358. You say that this was billed correctly. The Plan denied 
your request. The Plan says payment for code 99358 is bundled into payment for code 99309. 
 
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 99358 is a column II code to column I code 99309. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99358 billed for date of service May 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDX-Melanoma test (81529) provided March 15, 
2022. 
 
You asked the Plan to pay for the laboratory service. You say that this claim was denied in error and you are 
requesting it be reprocessed and paid. The Plan denied your request. The Plan says the Melanoma testing does 
not appear to be medically reasonable and necessary and is not covered by Medicare in this clinical situation. 
 
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found per the cited LCD, DecisionDx-Melanoma testing is covered only if the tumor is 
stage T1b or above, or T1a if there is documented concern about the adequacy of microstaging. The tumor 
stage is T1a, but there is no such concern regarding the adequacy of microstaging documented. The LCD also 
requires the presumed risk for a positive sentinel lymph node biopsy (SLNB) based on clinical, histological, or 
other information be greater than 5%. Per NCCN, "If a patient's risk of a positive sentinel lymph node (SLN) is 
less than 5%, NCCN does not recommend sentinel lymph node biopsy. This would include clinical stage IA, 
T1a melanoma with Breslow depth of less than 0.8 millimeters without ulceration or other adverse features, 
unless there is significant uncertainty about the adequacy of microstaging (positive deep margins)." In this case, 
the pathology report indicates the enrollee's tumor is stage T1a, 0.4 mm thick, and without ulceration. Thus, the 
enrollee does not have a presumed risk for a positive SLNB of greater than 5%. The review has determined that 
the records do not support that the enrollee meets the medically necessary criteria for Medicare coverage. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for DecisionDX-Melanoma test (81529) provided March 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested equipment is needed in 
order for the enrollee to be discharged from the facility safely. You say that the portable ventilator is necessary 
to prevent unnecessary hospital readmission. The Plan denied your request. The Plan says a home ventilator set 
in average volume-assured pressure support (AVAPS) mode with auto-EPAP (AE) that could be delivered by 
bi-level positive airway pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a portable ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the record indicates that the 
enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The record indicates that the enrollee was successfully treated with BiPAP.  The provided primary source documentation does not 
contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee 
could be treated with a BiPAP machine with AVAPS capability.  The Plan has indicated coverage for such a 
device is available upon request. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99214) with a neurologist to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you disagree with the denial and would like to 
request reconsideration. The Plan denied your request. The Plan says the OON provider does not provide any 
specialty service that the Plan's participating provider(s) cannot provide and is within the Medicare allowable 
distance and time therefore the Health Plan does not have a network deficiency. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99214) with a neurologist to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the copayment for wrist x-rays provided on July 30, 2021. 
 
You asked the Plan to waive the copayment for the wrist x-rays. You say that the x-rays should be included 
under post-op care. The Plan denied your request. The Plan says that you were charged this cost sharing 
correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not forwarded a copy of the 2021 Evidence of 
Coverage (EOC). Without this contractual information, we are unable to verify the cost sharing applied in this 
case. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the denial is not 
substantiated, and we must find in your favor. Therefore, we decided that the Plan has to waive the copayment 
for wrist x-rays provided on July 30, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218). 
 
You asked the Plan to pre-approve a fluid circulating cold pad with pump. You say that your provider has 
planned shoulder replacement surgery. The requested item is for the post operative management of your 
shoulder. The Plan denied your request. The Plan says the request for a fluid circulating cold pad with pump 
does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say a fluid circulating cold pad with pump will be denied 
as not reasonable and necessary. 
 
 We looked at the file and Medicare rules. Specifically, this item is not a covered benefit with Medicare or the 
Plan. Based on this information, we decided that Medicare rules for coverage of a fluid circulating cold pad 
with pump have not been met. Therefore, we decided that the Plan does not have to pre-approve a fluid 
circulating cold pad with pump (E0218).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled-nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is a 
medical necessity for you. The Plan denied your request. The Plan says you have exhausted your SNF benefit 
for the current benefit period. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from March 16, 2022, to 
September 29, 2022. The Plan has covered 100 days of SNF care. 
 
 
 
 
 
 
 
 Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve continued SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided May 26, 2021. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that the testing was medically necessary. 
The Plan denied your request. The Plan says the PCR testing is considered unproven and not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that urinalysis is the standard of care for urinary tract 
infection (UTI).  
 
We looked at the file and Medicare rules. The file shows that the services at issue exceeded the standard of care 
for the diagnosis and treatment of a UTI. Based on this information, we decided that Medicare rules for 
coverage of the urine PCR panel testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the urine polymerase chain reaction (PCR) panel testing provided May 26, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90837) provided on March 30, 
2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy services 
(90837) provided on March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) 
provider. 
 You asked the Plan to pre-approve a continuation of care with an OON provider. You say that previous 
authorizations have been approved in the past for a continuation of care OON. The Plan denied your request. 
The Plan says the enrollee is not in a current treatment plan with the OON provider, and they have participating 
providers who are available and can provide the care needed. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 a continuation of care with an OON 
provider. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician 
reviewer found there was no provided information in the documentation or correspondence that suggests an in-
network doctor of equal specialty could not effectively provide the care needed. The enrollee is being treated 
with antibiotics which does not require continued consultation with the current physician exclusively as the 
enrollee can begin seeing another infectious disease specialist to continue or switch antibiotics regimens easily 
and safely. The Plan has identified an alternative physician for the enrollee to consider. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a continuation of care with an OON provider have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) 
provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (97110) provided on June 29, 2020. 
 
You asked the Plan to pay for therapy services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says there is a more appropriate code for the service 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. 
 
In this case, the CPT Code Manual definition of code 97110 is Therapy procedure using exercise to develop 
strength, endurance, range of motion and flexibility, each 15 minutes. 
 
We find that CPT code 97110 is not supported in the medical record. Specifically, the service was provided in 
the home setting. There is a more appropriate code to represent this service (G0157). Based on this 
information, we decided that Medicare rules for coverage of therapy services have not been met. Therefore, we 
decided that the Plan does not have to pay for therapy services (97110) provided on June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a screening ultrasound study for abdominal aortic aneurysm 
(76706) billed for date of service April 1, 2022. 
 
You asked the Plan to pay for an ultrasound study of the abdominal aorta. You say that the service at issue was 
a medical necessity for the enrollee. The Plan denied your request. The Plan says the provided diagnosis code 
does not support the code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for an ultrasound study of the abdominal aorta. Our reviewer 
says that the code at issue does not meet criteria for payment. Our reviewer found that the radiology report 
describes a routine ultrasound abdominal aortic aneurysm screening for diagnosis code Z13.6, Encounter for 
screening for cardiovascular disorders. In this case, the available documentation does not support Medicare 
guidelines. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ultrasound study of the abdominal aorta have not been met. Therefore, we 
decided that the Plan does not have to pay for a screening ultrasound study for abdominal aortic aneurysm 
(76706) billed for date of service April 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on October 1, 2021, to 
November 22, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that you realized that you did not go to the proper 
doctor, however, you did what you had to do at that time because it was the best option for your pain. 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 chiropractic services provided on October 1, 2021, 
to November 22, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced knee and foot with 
ankle (CPT code(s): L5814, L5848, L5981 and L5986). 
 
You asked the Plan to pre-approve the prosthesis. You say that this device is necessary and should be covered 
by your Plan. The Plan denied your request. The Plan says this device is necessary and should be covered by 
your Plan. 
 
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 prosthesis. Our physician reviewer 
found the requested prosthetic leg with an advanced knee and foot with ankle (CPT code(s): L5814, L5848, 
L5981 and L5986) exceeds your functional needs and is not medically necessary per Medicare's LCD: Lower 
Limb Prostheses (L33787). The treating medical provider documentation does not support that you require the 
requested K3 level components to meet your functional needs. 
 
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 prosthesis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a prosthetic leg with an advanced knee and foot with ankle (CPT code(s): L5814, L5848, 
L5981 and L5986).