Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says the 
enrollee's needs can be met at a lower level of care. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 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 IRF admission and services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 70480 provided on December 6, 2021. 
 
You asked the Plan to pay for procedure code 70480. You say that this service was necessary and should be 
paid. The Plan denied your request. The Plan says that the payment for code 70480 is bundled into the payment 
for code 70450. Separate payment cannot be made. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not submitted any information to show that procedure 
code 70450 was also billed by the same facility and/or provider on the date in question. With no evidence that 
70450 was provided or billed, the Plan's denial is not substantiated. Therefore, we decided that the Plan has to 
pay for procedure code 70480 provided on December 6, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a portable oxygen concentrator (E1392) and DME 
delivery, set up, and/or dispensing service component (A9901) provided on March 30, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to reimburse you for a portable oxygen concentrator and DME delivery. You say that your 
primary care physician (PCP) requires you to be on oxygen at all times. You decided to purchase a portable 
unit to allow you to move around more freely and be able to enjoy all daily activities such as going to church 
and participating in volunteering at your church. The Plan denied your request. The Plan says only care from an 
in-network provider outside of emergent and urgent situations will be covered by your plan. 
 
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 reimburse you 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 reimburse you for these 
items/services. Therefore, we decided that the Plan does not have to reimburse you for a portable oxygen 
concentrator (E1392) and DME delivery, set up, and/or dispensing service component (A9901) provided on 
March 30, 2022, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pre-approve the electrocardiogram (ECG) (CPT code 93042) provided on May 
27, 2022. 
 
You asked the Plan to pre-approve the ECG. You say that the service is covered, and it was medically 
necessary. The Plan denied your request. The Plan says that the claim in dispute was not submitted with the 
appropriate modifier to allow payment. 
 
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. It appears that the Plans contracted delegate was provided the records for this 
admission and has failed to forward them to support the decision to deny based on the claim not having the 
appropriate modifier to allow payment. Therefore, we do not know if modifier 59 was used appropriately. 
Therefore, we decided that the Plan has to pre-approve the electrocardiogram (ECG) (CPT code 93042) 
provided on May 27, 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 anesthesia services (procedure code 01630) provided to the 
enrollee on January 27, 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 Current Procedural Terminology (CPT) code 01630-QK (187 units) remains 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 01630 is "Anesthesia for open or surgical arthroscopic 
procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; not 
otherwise specified." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the anesthesia billing code CPT 
01630-QK (187 units) was denied. In this case, the anesthesia time is 7:53-10:41 (which = 168 minutes)/15 
minutes = 11.2 units. CPT 01630 has 5 Base units. Base units + Time units = 5 + 11.2 = 16.2 total units.  This number of units would then be multiplied by the conversion factor and any appropriate modifier. The submitted 
anesthesiology bill of 187 units is not supported in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for anesthesia services (procedure code 01630) provided to the enrollee on January 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) device and 
supplies. 
 
You asked the Plan to pre-approve CPAP device and supplies. 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 in this policy, the term PAP (positive airway 
pressure) device will refer to both a single-level continuous positive airway pressure device (E0601) and a bi-
level respiratory assist device without back-up rate (E0470) when it is used in the treatment of obstructive sleep 
apnea. 
 
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 CPAP device and supplies. Our 
reviewer says that services are not medically necessary. Our physician reviewer found continued coverage of 
CPAP and supplies is considered not medically necessary because Medicare criteria are not met. The only 
records provided are the results of the home sleep test in January, making the diagnosis of obstructive sleep 
apnea (OSA). There are no records showing a followup clinician visit after starting CPAP confirming benefit, 
with compliance download confirming usage criteria are met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPAP device and supplies have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuous positive airway pressure (CPAP) device and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 30, 2021. 
 
You asked the Plan to pay for the office visit. 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 
services 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 an office visit provided on November 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1843). 
 
You asked the Plan to pre-approve the knee orthosis. You say that the knee orthosis is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a knee immobilizer without joints (L1830), or a knee 
orthosis with adjustable knee joints (L1832, L1833), or a knee orthosis, with an adjustable flexion and 
extension joint that provides both medial-lateral and rotation control (L1843, L1845, L1851, L1852), are 
covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s). 
 
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 knee orthosis. Our reviewer says 
that the requested knee orthosis is not medically necessary. Our physician reviewer found the enrollee has not 
had a recent injury or surgery to the knees. The patient is ambulatory with no evidence of objective knee laxity 
or instability on a physical exam. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a knee orthosis (L1843).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve side guards, the custom handrims, and the custom 
frame. 
 
You asked the Plan to pre-approve side guards, the custom handrims, and the custom frame. You say that the 
items are necessary. The Plan denied your request. The Plan says the custom accessories do not primarily serve 
a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve side guards, the custom handrims, and the custom frame.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77061 billed for date of service May 3, 2022. 
 
You asked the Plan to pay for procedure code 77061. You say that your coding team reviewed this claim and 
states that this is the correct code and modifier. You state this should be paid. 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 77061 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77061 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77061 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77061 billed for date of service May 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen validity testing (83789) provided on April 29, 
2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this testing is not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules 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 testing have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the specimen validity testing (83789) provided on April 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve adjustable foot platform, calf panel, and a cup holder. 
 
You asked the Plan to pre-approve adjustable foot platform, calf panel, and a cup holder. You say that the 
requested items 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 for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve adjustable foot platform, calf panel, and a cup holder.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 13, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on January 13, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided from February 17, 2022, through June 
14, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the bloodwork was done in-network; 
however, it was forwarded to another lab that is out-of-network. The Plan denied your request. The Plan says 
that the claim was processed accordingly with your 2022 EOC benefits. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the laboratory services by a contract provider. You state that you had the blood drawn by 
a network provider, which the Plan has not refuted; therefore, you cannot be expected to know that the sample 
would be sent to an out-of-network provider. Under Medicare rules, this means the laboratory services is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the laboratory services 
provided from February 17, 2022, through June 14, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdualag (CPT code J9298). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found the requested use of Opdualag is not FDA-approved for the enrollees diagnosis. The use is not 
supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & 
Medicaid Services (CMS)-approved medical journal. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Opdualag (CPT code J9298).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity orthosis (L8702). 
 
You asked the Plan to pre-approve the powered upper extremity orthosis. You say that the orthosis is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 powered upper extremity orthosis. 
Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is insufficient evidence in the literature that the MyoPro Orthosis will 
improve the long-term outcome for this patient, improve hemiparetic arm function, or be safe for long term use. 
 
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 powered upper extremity orthosis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a powered upper extremity orthosis (L8702).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 7, 
2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were unaware that 
the transportation services called were out-of-network. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $245 copayment for ambulance services.  
 
The enrollee has been asked to pay a $245 copayment for the ambulance services. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. This cost sharing applies regardless of whether 
or not the ambulance company is in or out of network. Therefore, we decided that the Plan does not have to 
waive the copayment for ambulance services provided on May 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that you would 
like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 
neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network specialists 
available to you that can provide the services you are requesting. 
 
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 
an office visit to be provided by an out-of-network (OON) provider.