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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited appeal 
for the denial of an LTACH admission. The Plan denied your request. The Plan says criteria for admission to 
the LTACH have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. 
 
 
 Our physician reviewer found the enrollee appears to still be somewhat unstable and requires additional acute 
care services that can safely be provided at the current facility until more stable and appropriate for transfer. 
There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to the LTACH would not be clinically advantageous and completion of treatment at 
the current facility is recommended.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Foundation Pain Index (FPI) assay (0117U) provided on 
November 22, 2022. 
 
You asked the Plan to pay for the FPI assay. You say that this test should be covered. The Plan denied your 
request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that code 0117U is non-covered for 
pharmacogenomic testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the FPI assay have not been met. Therefore, we decided that the Plan does not have to pay for the 
Foundation Pain Index (FPI) assay (0117U) provided on November 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lower 
extremity (73721). 
 
You asked the Plan to pre-approve an MRI of the lower extremity. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of the lower extremity. Our 
reviewer says that medical necessity of the requested MRI has not been established in the submitted records. 
Our physician reviewer found the physical exam was negative except for tenderness. There are no radiograph 
results are in the submitted records. There has been no conservative management including physical therapy.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lower extremity have not been met. Therefore, we decided that 
the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lower extremity (73721).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) 
 
You asked the Plan to pre-approve a power seat elevation system. You say that Medicare is now going to cover 
the power seat elevation system as long as the enrollee meets the coverage criteria. The Plan denied your 
request. The Plan says neither Medicare nor the enrollee's Medicare Advantage health plan covers this item. 
 
 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. Medicare rules also say that a power seat elevation feature (E2300) is non-covered because it 
is not primarily medical in nature.  
 
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 a power seat elevation system (E2300)
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure code Q0092 billed for date of service April 18, 2023. 
 
You asked the Plan to pay for the billed services. You say that the tests require separate units of code Q0092. 
The Plan denied your request. The Plan says that the extra units were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
The file shows that 4 x-ray procedures (72040, 72070, 72100, and 72220) were billed and paid for by the Plan. 
Carriers must pay a set-up component for each radiologic procedure. Based on this information, we decided 
that Medicare rules for coverage of the billed services have been met. Therefore, we decided that the Plan has 
to pay for procedure code Q0092 billed for date of service April 18, 2023.  
 
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 the Initial nursing facility care, and the care plan assessment 
provided on January 30, 2023, by an OON provider.  
 You asked the Plan to pay for the nursing facility care and the care plan assessment. You say that you are 
requesting reconsideration of the denied claim. The Plan denied your request. The Plan says this service was 
not authorized. 
 
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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 Initial nursing facility care, and the care plan 
assessment provided on January 30, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit provided on January 16, 2023. 
 
You asked the Plan to waive the cost share for an office visit. You say that you disagree with the cost share 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. Your 
contract with the Plan says that there is a $100 deductible and a $15 copayment which applies to 
physician/practitioner services.  
 
The item or service you asked the Plan to waive the cost share for falls within the physician/practitioner 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $100 deductible and a $15 copayment which applies to physician/practitioner services. You are being asked 
to pay your $100 deductible.  The total amount you are being asked to pay is $115 ($100 + $15 = $115). This 
cost sharing is a contractual obligation that had not been met at the time an office visit was received on January 16, 2023. Therefore, we decided that the Plan does not have to waive the cost share for an office visit provided 
on January 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and to pay for the 
panoramic radiographic image (D0330), the bone replacement graft (D7953) for tooth #29 and the fixed partial 
denture sectioning (D9120) provided on March 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dental procedures were recommended to 
prevent infection and they should be covered. The Plan denied your request. The Plan says your annual dental 
benefit for the year and the panoramic radiographic image has already been exhausted. Also, the denial of 
payment for the bone replacement graft and the fixed partial denture sectioning is correct because they are not 
covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
The record shows the Plan paid $137 for dental services on April 6, 2023, which was processed prior to the 
claim for the date of service of March 24, 2023. On April 7, 2023, the Plan paid $232 for dental services which 
was processed prior to the claim for the date of service of March 24, 2023. On April 11, 2023, the Plan paid 
$45 for dental services which was processed prior to the claim for the date of service of March 24, 2023. On 
May 17, 2023, the Plan paid $1,345 for dental services which was processed prior to the claim for the date of 
service of March 24, 2023. On March 24, 2023, the Plan paid $241 for dental services. For the year of 2023 the 
Plan paid $2,000 ($137 paid + $232 paid + $45 paid + $1,345 paid + $241 paid). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your annual dental benefit for the year of 2023 was exhausted on date of service of March 24, 2023. The 
record also shows the Plan paid for a complete series of radiographic images (D0210) on April 6, 2023, which 
was processed prior to the claim for the date of service of March 24, 2023; therefore, your benefit for the 
panoramic radiographic image (D0330) was exhausted on the date of service of April 6, 2023. bone 
replacement graft and the fixed partial denture sectioning are not covered under the Plan's dental benefit. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) and to pay for 
the panoramic radiographic image (D0330), the bone replacement graft (D7953) for tooth #29 and the fixed 
partial denture sectioning (D9120) provided on March 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 15, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are in the process of becoming in-network with 
the Plan. The Plan denied your request. The Plan says the services were not authorized. 
 
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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 office visit provided on February 15, 2023, by 
an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 11, 2022. 
 
You asked the Plan to pay for an office visit. You say that the services should be covered. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on October 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cup holder (A9900). 
 
You asked the Plan to pre-approve the cup holder. You say that the item should be covered. The Plan denied 
your request. The Plan says this item does not 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 the cup holder (A9900).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on October 13, 
2022. 
 
You asked the Plan to pay for an office visit and related services. You say that the services should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit and 
related services provided on October 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a quantitative calcium scoring (75571). 
 
You asked the Plan to pre-approve a quantitative calcium scoring. You say that you have high cholesterol, and 
this test is for artery calcium scoring. The Plan denied your request. The Plan says a quantitative calcium 
scoring was ordered as a screening test. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a quantitative calcium scoring, is being requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pre-approve a quantitative calcium scoring (75571).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve switch fender lights (K0108). 
 
You asked the Plan to pre-approve the switch fender lights. You say that the enrollee is no longer able to self-
propel an optimally configured manual wheelchair. You also say that the enrollee requires and 
meets Centers for Medicare & Medicaid Services (CMS) criteria for a K0848 base and all recommended 
components, as they do have a group 3 qualifying diagnosis and the need for advanced suspension. The Plan 
denied your request. The Plan says switch fender lights do not serve a medical purpose, and cannot be covered 
as it is not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. Medicare rules also say that an electronic interface used to control lights or other electrical 
devices is non-covered because it is not primarily medical in nature.   
 
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 switch fender lights (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that average volume assured pressure support (AVAPS) 
mode is a setting exclusive to the requested ventilator product. The Plan denied your request. The Plan says a 
ventilator is not covered by Medicare for this purpose and a bilevel positive airway pressure (BiPAP) device 
with AVAPS mode has not been found to be ineffective. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit for the evaluation and management provided on 
February 06, 2023. 
 
You asked the Plan to pay for a home visit for the evaluation and management. You say that the services were 
medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit for the 
evaluation and management provided on February 06, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that this is medically necessary. The Plan denied your 
request. The Plan says a ventilator is not covered by Medicare for this purpose and a bilevel positive airway 
pressure (BiPAP) device with average volume assured pressure support (AVAPS) mode would meet the 
enrollee's needs. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on March 14, 2023, to March 21, 
2023. 
 
You asked the Plan to pay for psychotherapy. You say that the services should be covered. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy provided 
on March 14, 2023, to March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99222) provided on June 25, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the services 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, the CPT Code Manual definition of code 99222 is the evaluation and management of a patient, 
requiring a comprehensive history; a comprehensive examination; and medical decision making of moderate 
complexity. 
 
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 physician services. Our reviewer says that the documentation does not support the billed code. Our reviewer found the documentation did not support a 
comprehensive history or physical as required. 
 
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 physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99222) provided on June 25, 2022.