Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
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 that the enrollee's medical conditions appear stable on outpatient medications with no 
issues that appear to require a physicians evaluation three or more times per week in a hospital setting. The 
provided medical records do not explain why the intensive inpatient rehabilitation therapy program is necessary and why therapy at a lower level of care such as in a skilled nursing facility is not appropriate for the enrollee. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on May 23, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a home visit. You say that this should be covered. The Plan denied your request. 
The Plan says there was no preauthorization by a primary care provider (this is different than a referral) for an 
out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 a home visit provided 
on May 23, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from April 
30, 2022, to May 6, 2022. 
 
You asked the Plan to pay for home health 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. The rules say that certain data elements on the NOA and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the NOA 
submitted for this series of care is incorrect. Therefore, we decided that the Plan does not have to pay for the 
home health services provided to the enrollee from April 30, 2022, to May 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services (procedure code 97140) received fromn 
April 5, 2022, to June 2, 2022. 
 
You asked the Plan to pay for the services. You say that you would like these claims processed and paid as you 
expected. The Plan denied your request. The Plan says the claims were denied correctly. 
 
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 chiropractic services (procedure code 97140) received fromn April 5, 2022, to 
June 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV), group 1 standard, 
patient weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve a group 1 POV wheelchair/scooter. You say that you have been waiting for 
this scooter since July. You cannot get transported without the requested scooter. The Plan denied your request. 
The Plan says the requested group 1 scooter is not the most appropriate mobility device for you at this time. 
 
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.  
 
The file shows that you were approved for a group 2 POV with another vendor, which was the most 
appropriate mobility device for you. This means that coverage of the requested group 1 POV has not been met. 
Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle (POV), group 1 
standard, patient weight capacity up to and including 300 pounds (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve the MyoPro Motion G orthosis. You say that this device is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the clinical value and 
effectiveness of device in the setting of left upper extremity partial paralysis following a stroke have not been 
demonstrated in the peer-reviewed literature. 
 
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 MyoPro Motion G orthosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities.  
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 MyoPro Motion G orthosis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the MyoPro Motion G orthosis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Zoll Lifevest provided on March 16, 2022. 
 
You asked the Plan to pay for Zoll Lifevest. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the item rendered was not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that a wearable defibrillator is covered for certain 
indications. 
 
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 Zoll Lifevest. Our reviewer says that the 
documentation does not support that Our physician reviewer found the documentation indicates that the 
ejection fraction improved to normal in January 2022 and the physician felt that the wearable defibrillator 
could therefore be discontinued as of February 8, 2022. The documentation does not support that the enrollee 
would be a candidate for a wearable defibrillator after that date according to current guidelines. In summary, 
authorization for continued use of a wearable defibrillator after February 8, 2022 would not be considered 
medically necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zoll Lifevest have not been met. Therefore, we decided that the Plan does not 
have to pay for Zoll Lifevest provided on March 16, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) of the heart. 
 
You asked the Plan to pre-approve a CT scan of the heart. The Plan denied your request. The Plan says that 
until there is documentation provided that this enrollee has never had an ischemic evaluation and that the 
enrollee is at least moderate risk for future coronary ischemic events, coronary calcium scoring is not clinically 
appropriate nor the generally accepted standard of care. The Plan also says the results of a coronary calcium 
score will not impact management and thus the coronary test is not clinically appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the heart. Our reviewer 
says that a CT scan of the heart is reasonable and necessary for the enrollee. Our physician reviewer found the 
enrollee has cardiomyopathy, a pacemaker, and left ventricular ejection fraction of 26%. Our reviewer also 
found that in light of the enrollee's significant cardiac history and hyperlipidemia, the request for a CT coronary 
calcium scoring is reasonable and indicated in order to stratify risk for ischemic cardiac disease and decision 
making for type of statin therapy. 
 
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 CT scan of the heart have been met. Therefore, we decided that the Plan has to 
pre-approve a computed tomography (CT) of the heart.  
 
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 pay for the office visit (99203) provided on June 7, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the enrollee was not able to 
choose an in-network provider. You say that no other provider was allowed in the office during the coronavirus 
pandemic. The Plan denied your request. The Plan says the service was not urgent or emergent. The Plan also 
says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the office visit (99203) provided on June 7, 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 an air purifier. 
 
You asked the Plan to pre-approve an air purifier. You say that this is necessary for your living space. The Plan 
denied your request. The Plan says this item is not covered by Medicare or the Plan. 
 
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 pre-approve an air purifier.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 5, 2022, through 
June 3, 2022. 
 
You asked the Plan to pay for home health services. You say that the NOA was sent with the initial claim and 
the claim should be reprocessed for payment. The Plan denied your request. The Plan says a valid NOA is 
required in order to process the final claim. 
 
The Plan must follow Medicare rules. Medicare rules say that home health services under a plan of care are 
paid based on a 30-day period of care. HHAs submit an NOA at the beginning of an admission and then submit 
one claim for each 30-day period of care. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the NOA was not submitted. Therefore, we 
decided that the Plan does not have to pay for home health services provided from May 5, 2022, through June 
3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mammmogram provided on July 20, 
2022. 
 
You asked the Plan to waive the copayment for a mammmogram. You say that this should be a screening, 
without a copayment. 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 $20 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $20 copayment for a mammmogram. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies 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. This was coded as a diagnostic mammogram. Therefore, we 
decided that the Plan does not have to waive the copayment for a mammmogram provided on July 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on September 27, 2021. 
 
You asked the Plan to pay for the testing services. You say that the test was medically necessary. The Plan 
denied your request. The Plan says the clinical utility of the testing cannot be determined. 
 
 The Plan must follow Medicare rules. Medicare rules say that 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. 
 
We looked at the file and Medicare rules. In this case, there are insufficient medical records from the treating 
physician to show that the results of testing would be used in the management of a specific medical problem. 
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab testing services provided on September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood bank physician services coded 86078 provided on 
June 2, 2022. 
 
You asked the Plan to pay for the blood bank physician services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the service is 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. 
 
In this case, the CPT Code Manual definition of code 86078 is blood bank physician services; investigation of 
transfusion reaction including suspicion of transmissible disease, interpretation and written report.  
We find that CPT code 86078 is not supported in the medical record. Specifically, modifier 91 (repeat clinical 
diagnostic laboratory test) is used to indicate that the same clinical laboratory procedure was performed on the 
same date of service to obtain subsequent (multiple) results. This modifier may not be used when a normal, 
one-time, reportable result is all that is required. Modifier 91 is not used when the second test is from a 
different site. Modifier 91 may not be used when there is a HCPCS or CPT code that describes a series of 
results. Based on this information, we decided that Medicare rules for coverage of the blood bank physician 
services have not been met. Therefore, we decided that the Plan does not have to pay for the blood bank 
physician services coded 86078 provided on June 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve a CGM and related supplies. You say that the requested items are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for CGMs and 
related supplies have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes. 
Based on this information, we decided that Medicare rules for coverage of a CGM and related supplies have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a CGM and related supplies.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from April 
1, 2022, to April 30, 2022. 
 
You asked the Plan to pay for home health 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. The rules say that certain data elements on the NOA and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, an NOA 
claim was submitted for the period of care; however, the final home health claim does not have a matching 
admission date of January 1, 2022. Therefore, we decided that the Plan does not have to pay for the home 
health services provided to the enrollee from April 1, 2022, to April 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 20, 2022, billed with 
codes 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81355, 81335, 81401 
and 0031U. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and were ordered by the enrollee's treating physician. The Plan denied your request. The Plan says panel testing 
should be billed using one CPT code on the claim. In addition, these tests do not meet the criteria for medical 
necessity. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 20, 2022, billed with codes 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 
81328, 81355, 81335, 81401 and 0031U.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination of the chest provided on 
May 9, 2022. 
 
You asked the Plan to pay for the radiologic examination of the chest. You say that you are unable to see if the 
place of service is correct as you do not have access to the hospital records. The Plan denied your request. The 
Plan says the radiology services were performed in an inpatient setting with the admission date March 28, 2022 
and the discharge date May 11, 2022 and the service date May 9, 2022 falls between the admission and 
discharge date of the inpatient claim. Place of service 22 is not appropriate, this service was considered to be 
performed in an inpatient setting as the date of service falls between the admission and discharge date of an 
inpatient claim. 
 
The Plan must follow Medicare rules. Medicare rules say that for all services (with two (2) exceptions), the 
place of service (POS) code to be used by the physician or other supplier will be assigned as the same setting in 
which the beneficiary received the face-to-face service. The two exceptions are for enrollees who are registered 
hospital inpatients or outpatients, in which case, the inpatient or outpatient hospital POS code would be 
reported regardless of where the face-to-face service takes place. We looked at the file and Medicare rules. Medicare says for all services (with two (2) exceptions), the place of 
service (POS) code to be used by the physician or other supplier will be assigned as the same setting in which 
the beneficiary received the face-to-face service. The two exceptions are for enrollees who are registered 
hospital inpatients or outpatients, in which case, the inpatient or outpatient hospital POS code would be 
reported regardless of where the face-to-face service takes place. Based on this information, we decided that 
Medicare rules for coverage of the radiologic examination of the chest have not been met. Therefore, we 
decided that the Plan does not have to pay for a radiologic examination of the chest (code 71045) provided on 
May 9, 2022.