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

 
We decided that the Plan does not have to pay for the surgical services rendered on September 1, 2021. 
 
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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that Place of Service (POS) code 24 must be billed on 
Form CMS-1500 for ambulatory surgical center (ASC) services. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed on the CMS-1500 form. 
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 surgical services rendered on September 1, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on December 27, 2021. 
 
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 70450 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography 
angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with 
column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the 
head/brain rendered on December 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on April 15, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you passed 
out and were unconscious and your daughter called 911 for emergency response. You also say that you refused 
to be transported because your daughter is a minor and you could not leave her alone. The Plan denied your 
request. The Plan says no transportation occurred; therefore, this service is not covered under Medicare and no 
payment can be made. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 15, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on April 15, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the radiology services rendered on December 14, 
2021. 
 
You asked the Plan to waive the copayment for the radiology services. You say that you did not know the 
provider did not obtain prior authorization. The Plan denied your request. The Plan says that the cost sharing 
applied is correct. 
 
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. The Plan did not send us the applicable Evidence of Coverage for your contract 
with the Plan. Without the Evidence of Coverage, we cannot determine whether any cost-sharing benefit 
applies to radiology services or if the cost-sharing amount you are being asked to pay is correct. Therefore, we 
decided that the Plan has to waive the copayment for the radiology services rendered on December 14, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided on August 11, 2021. 
 
You asked the Plan to pay for the home health care services. You say that this claim is not an inpatient hospital 
claim and was denied in error. You also say that you would like this claim to be reprocessed for payment. The 
Plan denied your request. The Plan says the non-contracted provider did not submit the RAP claim for services 
for date of service August 11, 2021 within 5 calendar days from the start of care. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days of the from the start of care date, August 11, 2021. Therefore, we decided that the 
Plan does not have to pay for the home health care services provided on August 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says three insulin injections are not received per day. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the monitor. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the record 
indicates that the enrollee has diabetes mellitus that is not treated thrice daily with insulin. The elements of the 
coverage criteria are not satisfied.  
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 32 physical therapy (PT) visits (97161). 
 
You asked the Plan to pre-approve additional PT visits. You say that you would benefit from additional 
physical therapy for your post-surgery care. The Plan denied your request. The Plan says the requested physical 
therapy services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the additional requested therapy generally is not accepted as 
specific and effective therapy for your condition beyond what was approved by the plan. You have had prior 
therapy, and the documentation does not reveal that you require the unique skills of a professional therapist to 
safely and effectively provide treatment, or that the services can only be safely and effectively performed by a 
therapist, or by or under the supervision of a therapist. You have had instruction in a home exercise program. 
The requested services are not part of a maintenance program, and the specialized skill, knowledge and 
judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain your 
current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 32 physical therapy (PT) visits (97161).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear (85060) provided on October 14, 2021. 
 
You asked the Plan to pay for the blood smear. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says payment for this code is not made for hospital 
outpatients. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 85060 is not supported in the record. Specifically, the record indicates that the enrollee 
was in an outpatient hospital setting on the billed date of service. CPT code 85060 has a professional/technical 
component indicator of 8.  
 
 This means that separate payment may be made only if the physician interprets an abnormal smear for hospital 
inpatient. No payment is recognized for CPT code 85060 when furnished to hospital outpatients or non-hospital 
patients.  Based on this information, we decided that Medicare rules for coverage of the blood smear have not 
been met. Therefore, we decided that the Plan does not have to pay for the blood smear (85060) provided on 
October 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cervical collar (L0180) provided on November 4, 2021. 
 
You asked the Plan to pay for a cervical collar. You say that the item at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the patients medical record adequately supports the medical necessity for the item.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The available medical records do not discuss the item at issue. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for a cervical collar (L0180) provided on November 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says as the power wheelchair is not covered, all other accessories and requested items 
requested to be added to this mobility device are therefore also not covered 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.  
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the documentation 
is conflicting about whether your mobility deficit significantly impairs MRADLs in the home, and is not 
ameliorated by a manual wheelchair. The wheelchair evaluation states the patient has fatigue, chronic 
obstructive pulmonary disease (COPD), and impaired cardio status. The medical progress note from the nurse 
practitioner does not document any cardiac or pulmonary issues. Your review of systems shows no shortness of 
breath. There are no cardiac or pulmonary medications noted. You are currently independent with ADLs with 
the current manual wheelchair. Furthermore, the wheelchair assessment states that you have fatigue when self-
propelling the chair long distances. You have sufficient upper body strength to propel a wheelchair. The 
documentation does not reveal any leg edema, contractures in the lower extremities, inability to flex the knees 
to require power elevating leg rests.The documentation does not reveal any spasticity, utilization of intermittent 
catheterization, or a high risk of skin breakdown. The documentation does not support that the requested 
wheelchair will significantly improve your ability to participate in MRADLs. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 20, 2021. 
 
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 the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on October 20, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient hospital services. 
 
You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says that 
inpatient care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 inpatient services. Our physician 
reviewer found that the enrollee presented to the emergency room with an elevated blood pressure of 220/110. 
The physical exam was unremarkable. A chest x-ray demonstrated milt pulmonary edema. She was treated with 
intravenous medications and admitted to telemetry. She was evaluated by Neprhology. The review has 
determined that the record showed that the patient's necessary hospital care would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient services have been met. Therefore, we decided that the Plan has to pre-
approve inpatient hospital 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug services rendered on October 11, 2021. 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid 
for Medicare purposes. 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Billed procedure codes S0077 (injection, clindamycin phosphate, 300 
mg) and S0119 (ondansetron, oral, 4 mg [for circumstances falling under the medicare statute, use hcpcs q 
code]) have a status indicator of I and are not valid for Medicare purposes. Therefore, we decided that the Plan 
does not have to pay for the drug services rendered on October 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or brain 
(70450) provided on December 29, 2021. 
 You asked the Plan to pay for a CT scan of the head or brain. You say that you have provided records to 
support the level of service. The Plan denied your request. The Plan says rules for payment have not been met 
because the service at issue is inclusive to another billed code. 
 
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 70450 
is a column II code to column I code 70496. 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 a computed tomography (CT) scan of the head or brain (70450) 
provided on December 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator for the enrollee. 
 
You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says that records do not show the enrollee tried a bi-level positive airway pressure 
(BiPAP) that did not help the enrollee's breathing or improve the amount of oxygen in her lungs. 
 
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 a home ventilator is not medically reasonable and necessary. This patient was recently hospitalized with 
pneumonia, congestive heart failure (CHF) exacerbation, COPD exacerbation, and acute on chronic 
hypercarbic respiratory failure requiring intubation.  
 There is a diagnosis of obstructive sleep apnea (OSA), and severe obesity. The patient has previously been 
noncompliant with continuous positive airway pressure (CPAP) and oxygen at home. There is no evidence the 
patient has been tried on BiPAP with average volume-assured pressure support (AVAPS) at home. There is no 
arterial blood gas analysis (ABG) done while stable as an outpatient to confirm chronic CO2 retention. 
Medicare does not cover a home ventilator when used as BiPAP. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for a home ventilator. 
 
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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Lunesta tablet 2mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered drug falls under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve a Lunesta tablet 2mg for the 
enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transurethral water ablation of prostate (0421T). 
 
You asked the Plan to pre-approve the transurethral water ablation of prostate. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that this service will be covered when the criteria listed in 
the Medicare Rules section of this letter 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 the transurethral water ablation of 
prostate. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
provided documentation did not show a low enough urinary flow rate (<15 cc/s), a sufficient IPSS (need 12 or 
more) to meet criteria for this procedure. 
 
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 transurethral water ablation of prostate have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the transurethral water ablation of prostate (0421T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FreeStyle Libre Continuous Glucose Monitor (CGM) 
provided on May 10, 2021. 
 
You asked the Plan to pay for the CGM. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the documentation submitted does not support that the 
enrollee's physician discussed the need for this item. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the documentation submitted does not support that the enrollee's physician discussed 
the need for the billed CGM. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the FreeStyle 
Libre Continuous Glucose Monitor (CGM) provided on May 10, 2021.