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

 
We decided that the Plan does not have to pre-approve a percutaneous image guided lumbar decompression 
(0257T). 
 You asked the Plan to pre-approve a percutaneous image guided lumbar decompression. You say that the 
services are necessary. The Plan denied your request. The Plan says the enrollee is not participating in a clinical 
trial. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve a percutaneous image guided lumbar decompression as part of a 
clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we 
decided that the Plan does not have to pre-approve a percutaneous image guided lumbar decompression 
(0257T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power options (K0861) and related accessories. 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and related accessories. You say that 
the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says the 
request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Group 3 standard power wheelchair 
and related accessories. Our reviewer says that the requested items not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee has a mobility deficit. The documentation 
does not clearly support that the enrollee's mobility deficit is due to a neurological condition (including post-
polio), myopathy, or congenital skeletal deformity. The treating physician's wheelchair evaluation does not list 
the qualifying diagnosis, post-polio syndrome, in the assessment section of their office visit note dated June 14, 
2022. The physician documentation does not reveal that the enrollee is at high risk for development of a 
pressure ulcer, utilizes intermittent catheterization for bladder management, or needs a power seating system to 
manage increased tone or spasticity. The enrollee is able to perform pressure relief and has 4- to 4/5 arm 
strength to perform and effective pressure relief. Therefore, the request for power and tilt exceeds the enrollee's 
medical needs as does the Group 3 power wheelchair. 
 
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 Group 3 standard power wheelchair and related accessories have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair 
with multiple power options (K0861) and related accessories.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay an additional $158.50 for the hearing services. We decided that the Plan 
does not have to waive the coinsurance or pay anything more than $1,000 for the hearing services.  
 
You asked the Plan to pay more for the hearing screening (V5008), hearing aids (V5261), assessment for 
hearing aid (V5010), and conformity evaluation (V5020) provided on April 13, 2022, by an out-of-network 
(OON) provider.. You say that you would like the Plan to remit the difference of $433. The Plan says that this 
claim paid correctly.  
We decided that the Plan has to pay an additional $158.50 for the hearing services.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan pays up to 
$1,000 every three years for hearing aids. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that the Plan paid a total of $841.50 
for the covered services. The record does not show that the Plan made any previous payment toward the $1,000 
benefit, and the maximum benefit of $1,000 has not been met. We find that the Plan must pay an additional 
$158.50 for the hearing services to meet the full $1,000 maximum allowance. Based on this information, we 
decided that the Plan's rules for coverage of the hearing screening, hearing aids, assessment for hearing aid, and 
conformity evaluation have been met. Therefore, we decided that the Plan has to pay an additional $158.50 for 
the hearing services.  
 
We also decided that the Plan does not have to waive the coinsurance or pay anything more than $1,000 
for the hearing services. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. 
 
We looked at the file and the Plan's rules. The contract clearly states that you are responsible for a 25% 
coinsurance, and then any amount over $1,000 every 3 years. Based on this information, we decided that the 
Plan's rules for coverage of the hearing screening, hearing aids, assessment for hearing aid, and conformity 
evaluation have not been met. Therefore, we decided that the Plan does not have to waive the coinsurance or 
pay anything more than $1,000 for the hearing services. 
 
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: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pay for 99291. We decided that the Plan does not have to pay for 99053.  
 
You asked the Plan to pay for the emergency room services provided on April 16, 2022. You say that medical 
records were provided The Plan says that procedure code 99053 is not separately payable. 
 
We decided that the Plan has to pay for 99291.  
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is supported in the 
medical record. Based on this information, we decided that Medicare rules for coverage of have been met. 
Therefore, we decided that the Plan has to pay for 99291.  
 
We also decided that the Plan does not have to pay for 99053. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for 99053. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 2, 2021. 
 
You asked the Plan to pay for the lab services. You say that the denial of payment is incorrect. The Plan denied 
your request. The Plan says the rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that the lab testing was not billed with a valid modifier suitable for payment as required. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on November 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
November 8, 2022, to November 19, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are disputing the share 
cost. 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 $330 
copayment per day, days 1-5 for inpatient hospital care. This inpatient hospital stay lasted 11 days, resulting in 
a copayment amount of $1,650 ($330 per day for 5 days = $1,650). 
 
You have been asked to pay $330 copayment per day, days 1-5 for inpatient hospital care. This item/service 
falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
inpatient hospital care provided on November 8, 2022, to November 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service April 4, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this should be paid for. The Plan denied 
your request. The Plan says code 99153 is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does not have to pay for the additional moderate sedation time provided on date of service April 4, 2022, billed with 
code 99153.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the spinal canal 
and contents (72148). 
 
You asked the Plan to pre-approve an MRI of the spinal canal and contents. The Plan denied your request. The 
Plan says the records do not show that the criteria for coverage are met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the spinal canal and 
contents. Our reviewer says that an MRI of the spinal canal and contents is not reasonable and necessary. Our 
physician reviewer found during the most recent encounter of November 4, 2022, you were noted to have 
normal strength in your lower extremities and no abnormal neurological findings. There is no report of a 
lumbar spine plain film series. Our reviewer found that you have declined physical therapy (PT) in the past. 
Our physician reviewer also found that without any red flags and no conservative management to date 
including PT, the medical necessity of the requested MRI of the lumbar spine has not been established in the 
records provided. 
 
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 MRI of the spinal canal and contents have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the spinal canal and 
contents (72148).
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 the enrollee requires medically necessary physical 
and occupational therapy to maximize independence with activities of daily living and increase safety 
awareness to prevent falls and potential readmissions. Additionally, you say the enrollee will require 24/7 
nursing care. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF. 
 
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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you want to go to the skilled nursing facility. The 
Plan denied your request. The Plan says the SNF care is not medically necessary, and you are receiving 
adequate and necessary intensive rehabilitation in the inpatient rehabilitation facility. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the individual psychotherapy services (90832) provided May 
25, 2022, to June 22, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like to appeal your denial of 
service for an individual session. Although the doctor is not a Plan provider and is not recognized by Medicare, 
you would like to claim the doctor as an out of network psychologist. The Plan denied your request. The Plan 
says these services were rendered by a provider who is not recognized by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the individual psychotherapy services 
(90832) provided May 25, 2022, to June 22, 2022.
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 the enrollee just had surgery and needs to start the 
process of recovering. You say the enrollee is currently in the hospital and needs to be discharged to an IRF. 
The Plan denied your request. The Plan says criteria for admission to the IRF have 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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
has had a functional decline from their baseline level of function and would likely benefit from occupational 
and physical therapy, but they do not require the intensity of therapies provided on acute inpatient 
rehabilitation. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 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 Ondansetron.  
 
Benefits for Ondansetron 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at home COVID-19 testing provided on January 16, 2022 
to January 18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was not 
received from a network provider. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the at home COVID-19 testing provided on January 16, 2022 to 
January 18, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the brain. 
 
You asked the Plan to pre-approve a CT scan of the brain. You say that the enrollee had an acute change in 
mental status and needs to have stroke/transient ischemic attack ruled out. The Plan denied your request. The 
Plan says this request for a CT scan in addition to the MRI which was approved is not medically necessary 
because it exceeds the enrollee's medical need and is not as beneficial as the MRI which was already approved. 
 
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 brain. Our reviewer 
says that a CT scan of the brain is not reasonable and necessary for the enrollee. Our physician reviewer found 
an MRI of the brain was approved, but no report of same is in the records. The orders and plan stated an MRI 
of the brain was necessary. Our reviewer found that there is no mention of the need for a CT scan as well. The 
rationale for the denied CT is not addressed in the records submitted. Our physician reviewer also found that a 
CT exam some 7 weeks after initial clinical presentation is not indicated if the face of an already approved MRI 
of the brain with no report of same is in the records submitted. 
 
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 brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the brain.