Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair with multiple options. 
 
You asked the Plan to pre-approve the requested wheelchair. The Plan denied your request. The Plan says the 
wheelchair with the requested options exceeds the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices are only covered under 
certain medical indications.  
 
The file shows that a group 3 power wheelchair with power tilt, recline, and elevating leg rests were requested. 
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 requested wheelchair. Our physician 
reviewer found that the enrollee has a medical history including multiple sclerosis and a neurogenic bladder 
treated with a chronic indwelling catheter. The documentation does not indicate that the enrollee has any 
pressure injuries or requires intermittent catheterization of the bladder that would necessitate power tilt or 
recline. There is no documentation that supports the need for power elevating leg rests. The requested group 3 
power wheelchair with multiple power options is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power wheelchair with multiple options.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the abdomen and 
pelvis with contrast (74177) provided on February 25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a CT scan of the abdomen and pelvis with contrast. You say that the service was 
medically necessary. The Plan denied your request. The Plan says the service was not urgent or emergent, nor 
approved of in advance. 
 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 computed tomography (CT) scan of the 
abdomen and pelvis with contrast (74177) provided on February 25, 2022, by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 19, 2021. 
 
You asked the Plan to pay for the lab services. You say that you want the Plan to pay for the services. The Plan 
denied your request. The Plan says the provider is not eligible to perform the services billed. The provider is no 
longer credentialed or eligible for Medicare/Medicaid billing of services. The providers license has also been 
placed on permanent inactive status in the states of Missouri and Illinois; therefore, the billed services cannot 
be supported. 
 
The Plan must follow Medicare rules. Medicare rules say that section 1128 of the Social Security Act provides 
the authority to Medicare to exclude various health care providers from receiving payment under Medicare. 
When an exclusion is imposed, no payment is made to anyone for any items or services in any capacity 
furnished, ordered, or prescribed by an excluded party.  
 
   
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, we have confirmed that the pathologist listed on 
the lab report has been excluded from payments under the Medicare program. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 13, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on April 13, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for revascularization services (procedure code 37226) provided 
to the enrollee on April 19, 2022. 
 
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 a more appropriate code is 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 37226 is "Revascularization, endovascular, open or 
percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty 
within the same vessel, when performed." 
 
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 CPT 37226 codes for stent placement 
in the femoral-popliteal arteries. The documentation does not describe any stent placed in the femoral or 
popliteal arteries. A more appropriate code could be used.  
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 revascularization services (procedure code 37226) provided to the enrollee on April 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI. 
 
You asked the Plan to pre-approve an MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the type of magnetic resonance imaging or MRI requested is supported for a 
purpose other than the reason this study was requested. 
 
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. Our reviewer says that an MRI 
is not medically reasonable and necessary. You have persistent symptoms after carpal tunnel surgery and 
cervical radiculopathy is suspected. The record provided indicates that an MRI of the neck was planned. The 
requested service is not medically necessary and reasonable for the diagnosis and treatment of your clinical 
condition at this time. Our physician reviewer found that your condition does not meet criteria for an MRI. 
 
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 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an MRI.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93971 billed for date of service February 23, 
2022. 
 
You asked the Plan to pay for procedure code 93971. The Plan denied your request. The Plan says payment for 
code 93971 is bundled into payment for code 93970. 
 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 93971 
is a column II code to column I code 93970. 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 93971 billed for date of service February 23, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology services provided on May 26, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for surgical pathology services. You say that you would like to request 
reconsideration for payment. 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 surgical pathology services provided on May 26, 
2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve 3 fractions of Stereotactic Body Radiation Therapy (SBRT). 
 
You asked the Plan to pre-approve 3 fractions of SBRT. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that SBRT is covered when specific criteria are met. 
 
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 3 fractions of SBRT. Our reviewer says 
that the services are medically necessary. Our physician reviewer found based on published data and NCCN 
guidelines, SBRT is within the accepted standards of care (as elucidated by the ASTRO model policy). It meets 
the general medical necessity criteria by virtue of treatment furnished according to accepted standards of 
medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3 fractions of SBRT have been met. Therefore, we decided that the Plan has to 
pre-approve 3 fractions of Stereotactic Body Radiation Therapy (SBRT).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 29826, 29827, 23450, and 23430 billed for 
date of service October 19, 2021. 
 You asked the Plan to pay for procedure codes 29826, 29827, 23450, and 23430. The Plan denied your request. 
The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT codes 29826, 29827, 23450, and 23430 is 1. The MAI value for this code is 2. 
You billed 2 units of each code, exceeding the MUE. Based on this information, we decided that Medicare 
rules for coverage of procedure codes 29826, 29827, 23450, and 23430 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 29826, 29827, 23450, and 23430 billed for date 
of service October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 17, 2022, by an OON 
provider. 
 
 
 You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the date of 
service, June 17, 2022 as it was denied for no authorization. You say that you are submitting the medical 
records for review. The Plan denied your request. The Plan says the out-of-network services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on June 17, 2022, by an 
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 
February 23, 2022, to February 28, 2022. 
 
You asked the Plan to pay for home health services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home 
health services under a plan of treatment. 
 
We looked at the file and Medicare rules. The file shows that the claims were not billed with the required TOB 
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 home health services provided to the 
enrollee from February 23, 2022, to February 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you still require additional care. The Plan denied 
your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall and was discharged home. There is ongoing weakness. Your medical problems are stable. There are 
no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare 
criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an inpatient hospital stay from April 7, 2022, to April 
16, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says that the cost share has been applied 
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 did not send the Explanation of Benefits (EOB) for these 
dates of services. That means, we are unable to verify that the correct cost share was applied. Therefore, we 
decided that the Plan has to waive the copayment for an inpatient hospital stay from April 7, 2022, to April 16, 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. You have chronic obstructive pulmonary disease (COPD) and heart failure with preserved ejection 
fraction (HFpEF) and was hospitalized for acute respiratory failure in July and again in September, due to 
exacerbations of both COPD and HFpEF, and possibly pneumonia. Arterial blood gases (ABG) partial pressure 
of carbon dioxide (PaCO2) was near normal or normal, even when acutely ill, so it is unlikely that you have chronic carbon dioxide (CO2) retention. There is no documentation of failure of bilevel positive airway 
pressure (BiPAP) as an outpatient. Medicare does not cover a home ventilator when used as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq (J9022), as monotherapy. 
 
You asked the Plan to pre-approve Tecentriq. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Tecentriq. Our reviewer says that 
Tecentriq, as monotherapy, is not medically necessary. Our physician reviewer found Tecentriq, as 
monotherapy, is not Food and Drug Administration (FDA)-approved for the treatment of the enrollee's 
condition. The reviewer found that the requested use of Tecentriq is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the reviewer 
found that the requested use of Tecentriq, as monotherapy, is not medically reasonable or necessary in this 
case. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tecentriq (J9022), as monotherapy.