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

 
We decided that the Plan does not have to pre-approve an expandable controller, expandable controller harness, 
electronic connection, USB Charger Q Logic 3 with Mounting Bracket, backpack holder, Quantam back up 
camera, push handles and power seat elevation feature for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these items are medically necessary. The Plan 
denied your request. The Plan says that there is not a medical need to control these power options through the 
joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that for equipment to be covered, it must primarily serve a medical 
purpose. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily 
medical in nature. 
 
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 expandable controller, expandable 
controller harness and electronic connection. Our reviewer says that an expandable controller, expandable 
controller harness and electronic connection are not considered medically reasonable and necessary in this case. 
Provided records document that the enrollee is able to self-feed with set up assistance thus indicating she has 
adequate upper extremity function to operate the wheelchairs power options with their own switches. Our 
physician reviewer found that the enrollee's condition does not meet criteria for coverage of an expandable 
controller, expandable controller harness and electronic connection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. The USB Charger Q Logic 3 with Mounting 
Bracket, backpack holder, Quantam back up camera and push handles in this appeal do not serve a purpose that 
is primarily medical in nature. These items are available to the general public and would be helpful even to 
those who are not sick or injured. A power seat elevation feature is non-covered because it is not primarily 
medical in nature. Therefore, we decided that the Plan does not have to pre-approve an expandable controller, 
expandable controller harness, electronic connection, USB Charger Q Logic 3 with Mounting Bracket, 
backpack holder, Quantam back up camera, push handles and power seat elevation feature for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 26, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says an appropriate modifier was not billed in this case. 
 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 70480. 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 imaging services provided to the enrollee on October 26, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on October 12, 
2020. 
 
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 claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until December 14, 2021. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the emergency room (ER) services rendered on October 12, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for ultrasound services provided to the enrollee on November 8,
2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the provider did not bill as required by Medicare coding regulations.
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 76700
is a column II code to column I code 93976. 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 ultrasound services provided to the enrollee on November 8,
2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunofixation electrophoresis rendered on November 3, 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 billed codes are not valid.
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 codes 86333 and 86334 were not valid for the Laboratory Fee Schedule for the billed date of
service. 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 immunofixation electrophoresis rendered
on November 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occupational therapy services rendered on October 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 procedure code 97530 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 97530 is therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
We find that CPT code 97530 is not supported in the medical record. Specifically, the records show that the 
services were performed in the home setting and there is a more appropriate code for these services. 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 occupational therapy services rendered on October 1, 
2021.
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 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 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 documentation supports those services may be provided at a lower 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) guidance for placement of 
radiation therapy fields (procedure code 77014) provided to the enrollee from August 18, 2021, to August 23, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says CPT 77014 should not be reported separately in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. CPT 
77014 is not meant to be reported separately. 
 
In this case, the CPT Code Manual definition of code 77014 is "Computed tomography guidance for placement of radiation therapy fields." 
 
We find that CPT code 77014 is not supported in the medical record. Specifically, it is not appropriate to 
separately bill CPT 77014 in cases of IMRT planning. 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 computed tomography (CT) guidance for placement of radiation therapy fields (procedure code 77014) 
provided to the enrollee from August 18, 2021, to August 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport services provided on October 12, 2021.
You asked the Plan to pay for the ambulance transport services. You say that this transport was arranged by your provider to be brought to and from a doctor's appointment. The Plan denied your request. The Plan says non-emergency transportation by ambulance is appropriate if it is documented that the member's condition is such that other means of transportation could endanger the person's health and that transportation by ambulance is medically required.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for ambulance transport services provided on
October 12, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve left lower extremity revascularization, endovascular, open or 
percutaneous iliac artery, tibio-peroneal trunk, tibial and peroneal arteries, unilateral (CPT code(s) 37220-
37223 and 37228-37235). 
 
You asked the Plan to pre-approve the services. You say that you have to go through the iliac artery to get to 
fem/pop, and the tibio/peroneal are beyond that. The Plan denied your request. The Plan says that there is no 
documentation of greater than 50% stenosis in requested vessels. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation supports the medical necessity of the procedures in question. As the 
diagnostic angiogram has not yet been performed, is not possible to predict which vessels will ultimately be 
treated. Pre-approval of codes applying to interventions of the iliac, femoral popliteal, and tibial arteries is not a 
guarantee they will be covered if the angiogram does not reveal disease in those locations.  However, it is 
customary to proceed with intervention if an appropriate lesion is identified in the vessels in question. In this 
case, the patient has both claudication and rest pain. Rest pain constitutes a limb threatening condition. 
Treatments in any of the territories in question would be appropriate in the setting of a hemodynamically 
significant lesion and rest pain. Recommend conditional pre-approval with final approval based on the 
angiogram. 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 been met. Therefore, we decided that the Plan has 
to pre-approve left lower extremity revascularization, endovascular, open or percutaneous iliac artery, tibio-
peroneal trunk, tibial and peroneal arteries, unilateral (CPT code(s) 37220-37223 and 37228-37235).  
 
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 mass spectrometry of a non-drug analyte provided along 
with drug testing on March 4, 2021, billed with code 83789. 
 
You asked the Plan to pay for the mass spectrometry. You say that this claim should be paid in full. The Plan 
denied your request. The Plan says the drug testing was approved; however, no separate payment can be made 
for the validity testing. 
The Plan must follow Medicare rules. Medicare rules say that specimen validity testing is not separately 
reimbursed when provided with drug testing.  
 
The code at issue was billed for specimen validity testing. Therefore, we decided that the Plan does not have to 
pay for the mass spectrometry of a non-drug analyte provided along with drug testing on March 4, 2021, billed 
with code 83789.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (CPT code 0242U) provided on May 21, 2021.
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory service have not been met. CPT code 0242U remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the submitted medical records reflect a different date of service than the billed date of service. Of note, the date of service is the date the specimen was collected. In addition, the patient resides in New Jersey and the billing laboratory is located in Illinois; therefore, the billed code, the validity and accuracy of the claim cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory service (CPT code 0242U) provided on May 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311), power 
seat elevation system (E2300), and occupied transit system (K0108). 
 
You asked the Plan to pre-approve power wheelchair accessories. You say that these items are medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The power seat elevation system and occupied transit system in this appeal do not serve a purpose that is primarily medical in nature. These items are available to the general public and would be helpful even to those who are not sick or injured. 
 
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 for the expandable controller. Our reviewer says that 
the requested items are not medically reasonable and necessary. Our physician reviewer found that the 
expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311) and other 
types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head 
control, etc.) are not medically necessary per Local Coverage Article: Wheelchair Options/Accessories - Policy 
Article (A52504). The patient does not require non-proportional input devices (e.g., sip and puff, head array, 
etc.). The patient does not require a separate display (i.e., for alternate control devices), other electronic devices 
(e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant 
control. The patient has 3 power options of tilt, recline, and power elevating leg rests but the patient does not 
need to control the power options through a joystick. The patient's upper extremity strength and function 
support that the patient can control any power options through their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Therefore, we decided that the Plan does not 
have to pre-approve an expandable controller (E2377, E2313, E2311), power seat elevation system (E2300), 
and occupied transit system (K0108).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says your condition has improved, and you are no longer a threat to yourself or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 based on a review 
of the records, you do not meet the criteria for admission, as you were not shown to be a danger to yourself or 
others. You were compliant and cooperative with treatment, while not showing any threats to safety, as you 
await placement. You do not have any suicidal or homicidal ideation. There are no auditory or visual 
hallucinations. 
 
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 inpatient psychiatric services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service October 19, 2021. 
 
You asked the Plan to pay for procedure code 70450-26. You say that you have submitted medical records to 
support payment. The Plan denied your request. The Plan says this code is bundled into payment for another 
code 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, we have confirmed that code 
70450-26 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 procedure code 70450-26 billed for date of service 
October 19, 2021.
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 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 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 review indicates that the complexity of the enrollee's nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the massage therapy. You say that the myofascial release therapy is the only 
therapy that has brought improvement to your condition. The Plan denied your request. The Plan says the 
provider is out-of-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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
massage therapy to be provided by an out-of-network (OON) provider.