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

 
We decided that the Plan does not have to waive the copayment for CT scan provided on May 31, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you are disputing the share cost. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $180 
copayment for outpatient hospital services.  
 
You have been asked to pay $106.08 which is less than the $180 copayment for CT scan. This item/service 
falls within the outpatient hospital services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for CT scan provided on May 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (80061 84439 84443 and 85025) provided on 
June 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that this claim was denied in error. The Plan denied 
your request. The Plan says in the absence of clinical information, medical necessity and coverage cannot be 
determined. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the lab services have been met. The Plan requested medical records to review. These were nor received. There is inadequate information provided 
to review medical necessity. Therefore, we decided that the Plan does not have to pay for the lab services 
(80061 84439 84443 and 85025) provided on June 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 21, 2022. You asked the Plan to pay for laboratory services. You say that you accept Medicare payment, and these are 
covered services which should be paid. The Plan denied your request. The Plan says there is insufficient 
information to process this claim for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory services have been met. 
Specifically, no medical records were provided from the ordering physician to show that this physician is 
treating the enrollee and these services are medically necessary. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided on June 21, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve additional power wheelchair accessories (E2311, E2313, E2377). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says that there is no medical need to control the power options through the joystick. 
 
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 accessories. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the patient is non-ambulatory and requires a power wheelchair for mobility and performing his basic 
daily activities. He cannot perform pressure relief independently due to weakness and spasticity and has a 
history of a sacral pressure wound. The patient requires a power wheelchair with power tilt and recline for 
adequate pressure relief and positioning. He also requires power elevating leg rests for positioning, spasticity, 
and lower extremity edema. The complexity of his seating and positioning needs necessitates a more complex 
group 3 power wheelchair base. The expandable controller with harness and electronic connection are 
necessary to operate the group 3 power wheelchair base and the power tilt and recline and power elevating leg 
rests via a joystick. The patient is also noted to have impaired upper extremity coordination and requires a 
joystick that will control the power options properly and safely. Therefore, the expandable controller with 
harness and electronic connection is 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 accessories have been met. Therefore, we decided that the Plan has to pre-
approve additional power wheelchair accessories (E2311, E2313, E2377).  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service September 
29, 2022. 
 
You asked the Plan to pay for procedure code 76642. You say that this service was medically necessary. 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 code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service September 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
(E0601) and full-face mask used with positive airway pressure device (A7030) purchased March 29, 2022. 
 
You asked the Plan to pay for the CPAP device. You say that you were advised that a prior authorization was 
not required before obtaining the CPAP machine. You purchased the machine based on an assessment by your 
Pulmonologist. The Plan denied your request. The Plan says enrollees must receive their medical services 
from an in-network provider. If you go to a provider who is not eligible to participate in Medicare, you will be 
responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure 
(CPAP) device (E0601) and full-face mask used with positive airway pressure device (A7030) purchased 
March 29, 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 desperately need physical therapy after your 
recent surgery. The Plan denied your request. The Plan says the denial of authorization for IRF care is correct. 
 
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 you are medically stable and do not need rehabilitation physician close supervision 3 
times per week for ongoing management. While you would benefit from physical and occupational therapy, your needs can be safely met in an alternate lower intensity setting such as a skilled nursing facility. 
 
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: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99231) provided on June 15, 2022. 
 
You asked the Plan to pay for the 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 service have not been met. Review of the file shows that the 
initial procedure CPT code 31613 (Tracheostoma revision; simple, without flap rotation) was performed on 
date of service May 13, 2022. Both providers have the same specialty  Surgery. Per the Medicare Fee 
Schedule Data Base, CPT 31613 has a postoperative period of 90 days. An appropriate modifier was not billed 
indicating the evaluation and management service was unrelated from the global surgery period. Therefore, this 
is denied due to being considered as being a part of the global surgical package. Therefore, we decided that the 
Plan does not have to pay for subsequent hospital care (99231) provided on June 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in iVAPS mode with Auto-
EPAP (AE) that could be delivered by BiPAP is not covered. 
 
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 service is not medically necessary. Our physician reviewer found the enrollee was recently hospitalized 
with exacerbation of HFpEF and acute renal dysfunction. There is a diagnosis of COPD, but there are no 
pulmonary function tests. The enrollee has severe obesity and OSA, and likely obesity-hypoventilation 
syndrome. This enrollee may benefit from BiPAP with AVAPS during sleep. This has not been tried and 
shown to fail 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 (E0466).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit (CPT code 99213) provided on June 22, 2022. 
 
You asked the Plan to pay for the office visit. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the enrollee was enrolled in Hospice during the date of service. 
 
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 office visit have been met. The Plan's denial is not justified. 
They Plan states they confirmed via MARX that the enrollee was actively enrolled in Hospice between July 10, 
2022, through September 7, 2022, for the June 22, 2022, date of service. The date of service occurred before 
the Hospice election. Therefore, we decided that the Plan has to pay for the office visit (CPT code 99213) 
provided on June 22, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (81455) provided on April 6, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that this service should be covered. The Plan denied 
your request. The Plan says this service is not covered when provided OON without 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 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 the lab services (81455) provided on April 6, 
2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound, breast, unilateral, real time with image 
documentation, including axilla when performed; complete (76641) provided on September 14, 2022. 
 
You asked the Plan to pay for the ultrasound. 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 ultrasound have not been met. CPT code 76641 was not billed 
in accordance with Medicare National Correct Coding Initiative Policy Medically Unlikely Edits (MUE). This 
is not a medical necessity denial. We determined that our original decision to deny payment is correct. CPT 
code 76641 is not billed in accordance with Medicare National Correct Coding Initiative Policy. Medically 
Unlikely Edits (MUE). This is not a medical necessity denial. CPT code 76641 has an MUE value of 1, but 
billed 2 units. Therefore, we decided that the Plan does not have to pay for ultrasound, breast, unilateral, real 
time with image documentation, including axilla when performed; complete (76641) provided on September 
14, 2022.
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 the request cannot be approved at this time by Medicare or the plan, as there is no 
medical need for a single power option. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee's sensation is intact in the bilateral upper and lower extremities; therefore, the 
documentation does not support that the neurological condition of a stroke is causing the mobility deficit. The 
documentation does not support that the enrollee is at high risk for developing a pressure ulcer, uses 
intermittent catheterization for bladder management, or needs a power seating system for increased 
tone/spasticity. The E2311 Electro connect btw 2 sys thru drive 2+ Actuators, E2377 Expandable Controller 
and E2313 Expandable Controller Harness are not medically necessary. The requested items exceed the 
patient's medical needs. The patient does not require a ventilator, or 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's upper extremity strength and function support that the patient can 
control any power options through their own switches. The E2300 seat elevator does not serve a primary 
medical need and therefore 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 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 related to end-stage renal disease 
(ESRD) provided on May 5, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this laboratory does not have 
a contract with the dialysis facility regarding payment; therefore, these services should be paid separately. The 
Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 5, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six home physical therapy visits. 
 
You asked the Plan to pre-approve home therapy visits. You say that the additional visits are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
 
 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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee does not have documented skilled physical therapy needs. The enrollee can be treated 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve six home physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implantation of a leadless pacemaker (procedure code 
33274) provided to the enrollee on July 20, 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 this was not reported correctly. 
 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 33274 is "Transcatheter insertion or replacement of 
permanent leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous 
ultrasound, ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), 
when performed." 
 
We find that CPT code 33274 is not supported in the medical record. Specifically, this should have been 
reported with a diagnosis code and a modifier that indicates that this was provided as part of a clinical study. 
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 implantation of a leadless pacemaker (procedure 
code 33274) provided to the enrollee on July 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two pairs of routine eyewear purchased on July 25, 2022. 
 
You asked the Plan to pay for two pairs of routine eyewear. You say that the provider stated these glasses 
would be covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 
service.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when 1 pair of routine eyewear up to $400 per year. 
 
We looked at the file and the Plan's rules. The Plan provided documentation showing that one pair of routine 
eyewear has already been covered. Based on this information, we decided that the Plan's frequency limit for 
coverage of two pairs of routine eyewear has been exceeded. Therefore, we decided that the Plan does not have 
to pay for two pairs of routine eyewear purchased on July 25, 2022.