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

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with a single power option. 
 
You asked the Plan to pre-approve a group 3 power wheelchair with a single power option. 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 follows Medicare rules. Medicare rules say that power wheelchairs are 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 a group 3 power wheelchair with a 
single power option. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found based on the medical records provided there is no documentation that the group 3 power wheelchair with 
a single power option (power tilt) at issue in this case meets all Medicare criteria for medically reasonable and 
necessary for the enrollee. Provided medical records do not support that the enrollee is high risk for skin 
breakdown, has a history of pressure ulcer(s) or has had skin flap surgery. Records do not document the 
enrollee performs bladder self-catheterization and is unable to transfer independently or that the enrollee has 
increased muscle tone or spasticity. Thus, the power tilt and the single power option does not meet criteria. 
 
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 power wheelchair with a single power option have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with a single 
power option.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost for a primary care office visit provided on March 3, 2022. 
 
You asked the Plan to waive the cost for a primary care office visit. You say that you believe these claims were 
processed incorrectly and that you should not have a cost share to pay. The Plan denied your request. The Plan 
says that these claims were processed 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. The Plan has not forwarded an Evidence of Coverage (EOC) to us. Without the 
applicable Evidence of Coverage, we cannot determine whether the cost-sharing amount you were asked to pay 
is correct or justified. Therefore, we decided that the Plan has to waive the cost ($172.80) for a primary care 
office visit provided on March 3, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 15, 2021. 
 
You asked the Plan to pay for physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers 
require prior authorization. 
 
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 did not pre-approve the 
service 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 physician's services provided on December 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80307, G0480, 83789) provided on November 
29, 2021. 
 You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. In addition, specimen validity testing (represented by code 83789) is not separately payable from 
the drug testing services. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. Medicare rules also say that providers performing validity testing on urine specimens utilized for drug 
testing should not separately bill the validity testing. 
 
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, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. In addition, we find that the 
testing described by code 83789 is considered specimen validity testing which is not separately payable.  
Therefore, we decided that the Plan does not have to pay for lab services (80307, G0480, 83789) provided on 
November 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a OneTouch Verio Flex Meter. 
 
You asked the Plan to pre-approve a OneTouch Verio Flex Meter. 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 follows Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers as long as the enrollee retains access to all medically necessary items (including non-
preferred brands). 
 
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 OneTouch Verio Flex Meter. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that one of the health plan's preferred brands of glucose meter 
would not be sufficient in meeting the enrollee's medical needs. Provided records do not document any medical 
reason for use of the requested OneTouch Verio Flex Meter over one of the health plan's preferred brands of 
glucose meter.  
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 OneTouch Verio Flex Meter have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a OneTouch Verio Flex Meter.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost for a primary care visit provided on March 21, 2022. 
 
You asked the Plan to waive the cost for a primary care visit ($117.00). You say that you believe these claims 
were processed incorrectly and that you should not have a cost share to pay. The Plan denied your request. The 
Plan says that these claims were 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. The Plan did not forward the Evidence of Coverage (EOC) to us; therefore, we 
could not determine whether the cost-sharing amount you were asked to pay is correct or justified. Therefore, 
we decided that the Plan has to waive the cost for a primary care visit provided on March 21, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 home health physical therapy visits. 
 
You asked the Plan to pre-approve 9 home health physical therapy visits. 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 home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 9 home health physical therapy visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
documentation does not support that the enrollee requires additional skilled rehabilitation services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled rehabilitation services to 
effectively provide treatment, care, and/or services in order to improve the enrollees condition, perform a 
maintenance program to maintain the enrollees condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health services are 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 9 home health physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 9 home health physical therapy visits.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95819 provided on January 6, 2022. 
 
You asked the Plan to pay for procedure code 95819. 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. Medicare rules say that modifier -26 is required for separate payment of 
the PC services when furnished in a different payment locality than the TC. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required -26 modifier to allow for separate PC payment. Therefore, we decided that the Plan does not have to pay for 
procedure code 95819 provided on January 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 26, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim was 
billed with the incorrect date of service. 
 
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 payment for CPT code 81479 is not supported in the medical record. Specifically, the claim must 
be billed with the date the specimen was collected. The records show that specimens were collected on March 
17, 2022, and March 21, 2022. As such, the claim was billed with the incorrect date of service. 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 April 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve angioplasty, atherectomy, and stents (37221, 37224, 
37225, and 37226). 
 
You asked the Plan to pre-approve angioplasty, atherectomy, and stents. You say that the requested 
angioplasty, atherectomy, and stents are medically necessary. The Plan denied your request. The Plan says the 
requested angioplasty, atherectomy, and stents are 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 angioplasty, atherectomy, and stents. 
Our reviewer says that the requested angioplasty, atherectomy, and stents are not medically necessary. Our 
physician reviewer found the enrollee has a diagnosis of Atherosclerosis of native arteries of extremities with 
rest pain, bilateral legs. The Physical Findings dated August 16, 2022, contains conflicting documentation 
regarding the arterial exam. A Lower Extremity Arterial Duplex Report dated August 9, 2022, documents 
moderate to severe bilateral distal disease, with mild plaque in the right femoral and popliteal arteries, the left 
profunda femoris, femoral, and popliteal arteries. Moderate to severe right and left distal disease was 
documented. Triphasic and biphasic waveforms were noted throughout the right and left lower extremities. The 
clinical documentation is conflicting, and does not sufficiently support that the requested angioplasty, 
atherectomy, and stents are medically reasonable and necessary for the enrollee 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 angioplasty, atherectomy, and stents have not been met. Therefore, we decided 
that the Plan does not have to pre-approve angioplasty, atherectomy, and stents (37221, 37224, 37225, and 
37226).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adhesive bandages provided on May 25, 2022. 
 
You asked the Plan to pay for the services provided. You say that the payment allowed was not sufficient to 
meet expenses. The Plan denied your request. The Plan says the code is not eligible for reimbursement. 
 
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 A6413 is adhesive bandage, first-aid type, any size, each. 
We find that CPT code A6413 is not covered by Medicare. 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 
the adhesive bandages provided on May 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99251 billed for date of service April 21, 
2022. 
 
You asked the Plan to pay for procedure code 99251. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes. 
 
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 99251 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99251 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99251 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99251 billed for date of service April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right SI RFA (CPT code 64625). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says published studies do not demonstrate any long-term health outcome advantage with the 
use of SI joint RFA as an alternative to standard treatment 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed 
radiofrequency, is considered investigational and therefore, not medically necessary. The review has 
determined that the requested SI joint RFA is not medically reasonable or 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve right SI RFA (CPT code 64625).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Monovisc Hyaluronan injection (J7327). 
 
You asked the Plan to pre-approve a Monovisc Hyaluronan injection. The Plan denied your request. The Plan 
says the documentation does not show that the enrollee had a poor response to other drugs first. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Monovisc Hyaluronan injection. Our 
reviewer says that the enrollee does not meet the criteria for coverage for a Monovisc Hyaluronan injection. 
Our physician reviewer found there is no indication that the enrollee has tried and failed the required drugs. 
Our reviewer also found that there is no indication that the Plan's required drugs would likely be less effective 
and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Monovisc Hyaluronan injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Monovisc Hyaluronan injection (J7327).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical record. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. In 
addition, the medical records do not clearly identify which tests were performed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken.  
 
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, this claim was billed with an urgent care POS code (20). However, the records do not support that the sample was taken in an urgent care facility setting. 
Therefore, we decided that the Plan does not have to pay for lab services provided on March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code(s): E0466 and E0562). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the Medicare rules have 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 the home ventilator. Our physician 
reviewer found provided records document that the home ventilator is being requested for use in volume 
assured pressure support (TTV-VAPS) mode with auto-titration (AE) which could be provided by a bilevel 
positive airway pressure (BiPAP) device with average volume-assured pressure support (AVAPS) and a back-
up rate. As stated in the Lcd (L33800): "Claims for ventilators used to provide CPAP or bi-level CPAP therapy 
for conditions described in this RAD policy will be denied as not reasonable and 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code(s): E0466 and E0562).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 26, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support the services at issue. The Plan denied your request. The Plan says procedure code 99100 is considered 
bundled and not separately payable. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 80053) provided on April 
7, 2022. 
 
You asked the Plan to pay for the laboratory services. 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 services have not been met. The claim did not meet 
Medicare billing guidelines. The OCE program created edit 15 for HCPC 80053, which has a status code of 
"Q4". A claim processed with an edit 15 has a disposition of return claim to provider. The claim is not eligible 
for payment based on billing guidelines. Therefore, we decided that the Plan does not have to pay for the 
laboratory services (CPT code 80053) provided on April 7, 2022.