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

 
We decided that the Plan does not have to pay for the lab services provided on May 17, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab services 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 lab services provided on May 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination, spine, cervical and radiologic 
examination, spine, lumbosacral provided on October 31, 2022. 
 
You asked the Plan to pay for the radiologic examination, spine, cervical and radiologic examination, spine, 
lumbosacral. You say that x-rays are required at the beginning of the service so the chiropractor will know your 
medical condition and where treatment is needed, otherwise, he will be treating you blindly and this part of the 
service is needed for proper treatment. The Plan denied your request. The Plan says these services are not 
covered services under Medicare or under your Plan's Evidence of Coverage when provided by a chiropractor. 
 
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 a radiologic examination, spine, cervical and radiologic examination, spine, 
lumbosacral provided on October 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power scooter (K0807) and accessories 
(K0108). 
 
You asked the Plan to pre-approve a power scooter and accessories. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says that Medicare does not cover a Group 2 
scooter that has added features that are not needed in the home. 
 
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 rules also say that if the power wheelchair (PWC) base is not covered, 
then related accessories will be denied.  
 
 
 The requested Group 2 power scooter 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. In this case, the requested 
accessories are denied as the power scooter is not covered. Therefore, we decided that the Plan does not have to 
pre-approve a Group 2 power scooter (K0807) and accessories (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insertion of an intrauterine device (IUD) (58300) 
provided on October 31, 2022. 
 
You asked the Plan to pay for the IUD. You say that you had the IUD inserted for medical reasons. You also 
say that it is not for birth control, but is a treatment for your condition. The Plan denied your request. The Plan 
says this is a non-covered service under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the Physician Fee Schedule Status Indicator N 
means that the service billed is a non-covered service. 
 
 
 
 
 We find that procedure code 58300 has a status indicator of N on the Physician Fee Schedule. This means that 
procedure code 58300 is not a covered service. Based on this information, we decided that Medicare rules for 
coverage of the IUD have not been met. Therefore, we decided that the Plan does not have to pay for the 
insertion of an intrauterine device (IUD) (58300) provided on October 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polar care cube (A9999) purchased on August 3, 2022. 
 
You asked the Plan to pay for the polar care cube. You say that you believe this service should be covered 
because it is medically necessary for your knee. The Plan denied your request. The Plan says this item or 
service is not covered by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The record shows that the Plan found that there is no appropriate 
current procedural terminology code for the polar care cube, but code E0218 for a fluid circulating cold pad 
with pump is an appropriate code. The polar care cube you received is a type of cold therapy. Based on this 
information, we decided that Medicare rules for coverage of the polar care cube have not been met. Therefore, 
we decided that the Plan does not have to pay for the polar care cube (A9999) purchased on August 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services billed with code 99292 for 
September 26, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99292 is not supported. 
 
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 99292 is critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service). 
 
 
 
 
  
We find that CPT code 99292 is not supported in the medical record. Specifically, this is an add-on code that 
was not billed with a required primary procedure code. 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 the critical care services billed with code 99292 for September 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the above-ground pool (99199) purchased on June 27, 2022. 
 
You asked the Plan to pay for the above-ground pool. You say that you were provided a prescription for an 
above ground pool due to your disabilities. You also say that you are unable to participate in aquatic therapy in 
a public setting due to Raynauds syndrome, which hinders your ability to participate without having the ability 
to control the temperature of the water. The Plan denied your request. The Plan says the above-ground pool that 
is being requested does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the above-ground pool (99199) purchased on June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99233) rendered on 
August 10, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documents do not support the level of care. 
 
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 99233 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that for the date of service in question, 
the review has determined that the records did not support a detailed interval history and exam. The records did 
not support medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. 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 subsequent hospital care (procedure code 99233) rendered on August 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic connection (E2311) expandable controller 
(E2377) and expandable controller harness (E2313). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that please review the attached medical 
records for appeals. The Plan denied your request. The Plan says the available medical records do not support 
necessity of the upgraded electronics. 
 
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 upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided records document that the enrollee has 4+/5 to 5/5 bilateral upper 
extremity strength. The records do not document that the enrollee's upper extremity function is so impaired that 
it will prevent the enrollee from operating the wheelchair's power options with 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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the electronic connection (E2311) expandable controller (E2377) and expandable 
controller harness (E2313).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted multianalyte assay with algorithmic analysis 
(81599) provided August 8, 2022. 
 
You asked the Plan to pay for the Nodify CDT test. You say that the doctor regarded the Nodify CDT test as a 
medical necessary and valuable tool when determining treatment for the enrollee. The Plan denied your 
request. The Plan says this test is considered investigational as studies do not show that the requested blood test 
improves health outcomes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Nodify CDT test have not been met. Therefore, we decided that the Plan does not have to pay 
for the unlisted multianalyte assay with algorithmic analysis (81599) provided August 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration 
stating the enrollee would benefit from an LTACH admission to regain a maximum/prior level of functioning 
and continue a multidisciplinary approach to care. The Plan denied your request. The Plan says the LTACH 
admission you requested is not medically necessary. 
 
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. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care setting. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 400 units of Botox. 
 
You asked the Plan to pre-approve an additional 400 units of Botox. You say that you have been using 500 
units since October 2020. You say that the enrollee has been responding well. You also say that the enrollee 
has not had migraines since this treatment began. The Plan denied your request. The Plan says the additional 
units are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 an additional 400 units of Botox. Our 
reviewer says that an additional 400 units of Botox is not medically necessary. Our physician reviewer found 
the Food and Drug Administration (FDA) has stated that the prescribed Botox amounts should not exceed 400 
units per month. The Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Therefore, the reviewer found that an additional 400 units of 
Botox is not medically reasonable or 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 an additional 400 units of Botox have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an additional 400 units of Botox.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-one. 
 
You asked the Plan to pre-approve Synvisc-one. You say that chart notes that were not used in the original 
review have been submitted. The Plan denied your request. The Plan says their records do not show that the 
enrollee meets the requirements for Synvisc-one. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Synvisc-one. Our reviewer says that the 
criteria for coverage has not been met. Our physician reviewer found the diagnosis of osteoarthritis has not 
been confirmed. The records do not document that the enrollee has failed to respond adequately to conservative 
non-pharmacologic therapy and simple acetaminophen. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-one have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-one.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty hospital bed, with weight capacity greater 
than 350 pounds, but less than or equal to 600 pounds (Drive Bari) (E0301). 
 
You asked the Plan to pre-approve a Drive Bari. You say that this appeal was denied due to it being said it was 
not medically necessary, yet the enrollee's doctor is saying it is medically necessary for this specific bed for 
them. You also say the enrollee is not the 350 pounds, and is in a facility as stated in the denial but the doctor is 
stating that it is a medical necessity to have this bed to properly progress in their healing. The Plan denied your 
request. The Plan says the enrollee's current weight as of December 23, 2022, was 164 pounds. The Plan also 
says equipment is not covered by Medicare if the facility stay is non-covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed (E0301, 
E0303) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the 
beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds. 
 
We looked at the file and Medicare rules. Specifically, the records show that the enrollee is in a long-term 
facility, and weighs less than 350 pounds. Based on this information, we decided that Medicare rules for 
coverage of a Drive Bari have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
heavy duty hospital bed, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds 
(Drive Bari) (E0301).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for psychotherapy provided on September 21, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that these services were provided to you as part of 
the treatment you received at the medical center during the period of September 20, 2022 to  
September 22, 2022, when you were kept for treatment of an acute mental health crisis. You say that during 
those days you were in the center's Emergency Department under protective observation and supervision while 
receiving medication and psychotherapy to treat your condition. The Plan denied your request. The Plan says 
that this provider is not a Medicare Health Plan provider. 
 
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 provided us with the network status of the facility 
where you received the services at issue. Additionally, the Plan has not provided a Medicare rule to substantiate 
the denial. Therefore, we decided that the Plan has to pay for psychotherapy provided on September 21, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neurologist's consultation to be provided by the 
requested out-of-network provider. 
 
You asked the Plan to pre-approve a neurologist's consultation with the requested out-of-network provider. You 
say that you would like to see if the enrollee would be a candidate for magnetic resonance imaging (MRI) 
guided ultrasound therapy for essential tremor, which is a procedure that the Plan does not provide. You say the 
enrollee had deep brain stimulation (DBS) twice, and the probes had to be removed from the brain due to 
infections and he received the option from his surgeon for a third DBS surgery but does not wish to go through 
the procedure again. The Plan denied your request. The Plan says a neurology consult can be provided in-
network and there are participating providers with clinical expertise to treat this condition. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a 
neurologist's consultation to be provided by the requested out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a glycosylated hemoglobin test (83036) billed for date of 
service July 26, 2022. 
 
You asked the Plan to pay for a glycosylated hemoglobin test. You say that the service at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that glycated hemoglobin/protein testing is widely 
accepted as medically necessary for the management and control of diabetes. It is also valuable to assess 
hyperglycemia, a history of hyperglycemia or dangerous hypoglycemia. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a glycosylated hemoglobin test have not been met. Specifically, the available medical records do 
not support that the enrollee has a condition necessitating the use of the service at issue. Therefore, we decided that the Plan does not have to pay for a glycosylated hemoglobin test (83036) billed for date of service July 26, 
2022.