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

 
We decided that the Plan does not have to pay for a computerized dynamic posturography sensory organization 
test provided on June 6, 2023. 
 
You asked the Plan to pay for the computerized dynamic posturography sensory organization test. You say that 
the test was required because you are having problems with balance and dizziness. The Plan denied your 
request. The Plan says the computerized dynamic posturography sensory organization test is 
experimental/investigational. 
 
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 pay for the computerized dynamic posturography 
sensory organization test. Our reviewer says that the requested computerized dynamic posturography sensory 
organization test is not considered medically reasonable and necessary. Our physician reviewer found that the medical records and review of the current peer-reviewed medical literature do not document that use of the 
computerized dynamic posturography sensory organization test has been shown in controlled studies in a CMS-
approved journal to result in long term health benefits in patients with vertigo, balance problems and dizziness.  
 
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 computerized dynamic posturography sensory organization test have not 
been met. Therefore, we decided that the Plan does not have to pay for a computerized dynamic posturography 
sensory organization test provided on June 6, 2023.
Appeal type: ER
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 28470. We decided that the Plan does not have to pay 
for procedure code 99285.  
 
You asked the Plan to pay for procedure codes 28470 and 99285 provided on March 16, 2023. You say that the 
medical records support the billing of procedure codes 28470 and 99285. The Plan says that the medical 
records do not support the billing of procedure codes 28470 and 99285.  
We decided that the Plan has to pay for procedure code 28470.  
 
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 28470 is Closed treatment of metatarsal fracture; without manipulation, each. 
 
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 pay for procedure code 28470. Our reviewer says 
that the medical records support the billing of procedure code 28470. Our physician reviewer found the 
enrollee was given a splint; therefore, code 28470 is supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 28470 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 28470.  
 
We also decided that the Plan does not have to pay for procedure code 99285. 
 
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 99285 is Emergency department visit for the evaluation and management of a patient, which requires a 
medically appropriate history and/or examination and high level of medical decision making. 
 
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 pay for procedure code 99285. Our reviewer says 
that the medical records do not support the billing of procedure code 99285. Our physician reviewer found 
although there was an appropriate history and physical, the documentation did not sufficiently support a high 
level of medical decision making. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285. 
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve an inpatient right total knee replacement. 
 
You asked the Plan to pre-approve an inpatient right total knee replacement. You say that the provider feels 
like physical therapy was contraindicated and could harm the enrollee more than help them.  The Plan denied 
your request. The Plan says that the enrollee's pain is variable, and they have not completed a full 6-week 
course of physical therapy. 
 
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 an inpatient right total knee 
replacement. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has a significant past and/or current medical 
history that would place this enrollee at increased risk for peri-surgical complications requiring an inpatient 
stay.  Past medical history was positive for irregular heartbeat, high cholesterol, and arthritis. She has a history 
of carotid stenosis and left bundle branch block. Therefore, the requested inpatient stay is medically 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 an inpatient right total knee replacement have been met. Therefore, we decided 
that the Plan has to pre-approve an inpatient right total knee replacement.  
 
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 pre-approve a vitrectomy chair (E1399) and positioning cushion 
(E0190). 
 
You asked the Plan to pre-approve a vitrectomy chair and positioning cushion. You say that the items are 
medically necessary. The Plan denied your request. The Plan says these are not covered items. 
 
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 a vitrectomy chair (E1399) and positioning cushion 
(E0190).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the records provided support medical necessity. The 
Plan denied your request. The Plan says the IRF services you are requesting do not meet the requirements for 
approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided on March 21, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for acupuncture. You say that you are requesting reconsideration for the service 
provided. The Plan denied your request. The Plan says the enrollee must receive their care from a network 
provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives 
from an out-of-network provider (a provider who is not part of the plans network) will not be 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 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 acupuncture provided on March 21, 2023, by an 
out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the transplant related lodging, meals, and 
transportation (S9975) provided from April 7, 2023, to April 8, 2023. 
 
You asked the Plan to reimburse you for the transplant related services. You say that you submitted a request 
for reimbursement for travel in June 2021 and it was approved. You also say that this should be reimbursed. 
The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 17, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the transplant related services have not been met. Therefore, we decided that the Plan does not have to reimburse you for the transplant related lodging, 
meals, and transportation (S9975) provided from April 7, 2023, to April 8, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for office visits and 
psychotherapy services provided from March 23, 2022, to March 14, 2023.  
 
You asked the Plan to waive the deductible and coinsurance for the office visits and psychotherapy services. 
You say that the enrollee has an onerous debt that is taxing her finances and her mental health. 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. The 
enrollees contract with the Plan says that there is a $1000 deductible and a 50% coinsurance, which applies to 
outpatient mental health care.  
 
 The item or service you asked the Plan to waive the deductible and coinsurance for falls within the outpatient 
mental health care benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is a $1000 deductible and a 50% coinsurance, which applies to outpatient mental health care. This 
cost sharing is a contractual obligation that had not been met at the time the office visits and psychotherapy 
services were received from March 23, 2022 to March 14, 2023. Therefore, we decided that the Plan does not 
have to waive the deductible and coinsurance for office visits and psychotherapy services provided from  
March 23, 2022, to March 14, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from December 15, 2022, to 
December 20, 2022. 
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says no medical necessity for an out-of-network provider, such as an urgent or 
emergency situation, has been documented. There is no network deficiency for these services and alternate 
network providers were found. 
 
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 psychotherapy provided from December 15, 2022, to  
December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 21, 2023. 
 
You asked the Plan to pay for the physician's services. You say that the assisted living facility is responsible to 
obtain prior authorization for all of their patients, which should also cover the medical treatments provided by 
this doctor. The Plan denied your request. The Plan says 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 says 
that the Plan has also determined that these services are not urgent or emergent, nor were they approved in 
advance. 
 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 physician's services provided on March 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Inogen One G4 portable oxygen tank. 
 
You asked the Plan to pre-approve a Inogen One G4 portable oxygen tank. You say that the current tank you 
have is too heavy to carry and it is not helping with your back problems. The Plan denied your request. The 
Plan says Inogen One G4 portable oxygen tank is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. The rules say that Medicare considers equipment to 
be reasonable and necessary if the equipment does not serve the same purpose as other equipment already 
available to an 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 a Inogen One G4 portable oxygen tank 
Our reviewer says that a Inogen One G4 portable oxygen tank is not medically necessary. Our physician 
reviewer found that you have already been provided an oxygen concentrator home use and oxygen tanks and a 
cart for portability. The records show that you are stable and does not clarify why the cart is not acceptable and 
adequate for your portability needs. 
 
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 Inogen One G4 portable oxygen tank have not been met.  Therefore, we 
decided that the Plan does not have to pre-approve a Inogen One G4 portable oxygen tank.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 standard power wheelchair (K0823). 
 
You asked the Plan to pre-approve a Group 2 standard power wheelchair. You say that the requested item is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The physician order provided in the case record shows that the order is for a power operated vehicle (POV) or 
scooter. There is no physician order in the case record for the requested power wheelchair. This means that Medicare rules for coverage of the requested PMD have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Group 2 standard power wheelchair (K0823).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the heart. 
 
You asked the Plan to pre-approve a CT scan of the heart. You say that this not a standalone test and was 
ordered by your provider as being necessary. The Plan denied your request. The Plan says this test is not 
medically necessary as a standalone test. 
 
The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered 
service and will be denied as not medically necessary. Calcium scoring reported in isolation is considered a 
screening service. When performed in association with CT angiography, there is neither separate nor additional 
included reimbursement for the calcium scoring. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CT scan of the heart have not been met. Therefore, we decided that the Plan does not have to pre-
approve a CT of the heart.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are unable to walk and require IRF services 
because you cannot be safely discharged home. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 17, 2023, billed with 
codes 87471, 87481, 87500, 87551, 87640, 87641, 87651, 87653, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. 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. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met.  
 
Medicare rules also say that providers must report services correctly. Providers must report services with the 
appropriate CPT code. In this case, we have also confirmed that code 87640 is a column II code to column I 
code 87641. The records do not support the modifier billed to bypass the edit.  
 
Lastly, procedure code 87798 is not supported. Specifically, this code is a not otherwise specified code, and the 
documentation does not contain a complete description of the not otherwise specified code. 
 
Therefore, we decided that the Plan does not have to pay for the genetic testing provided on January 17, 2023, 
billed with codes 87471, 87481, 87500, 87551, 87640, 87641, 87651, 87653, and 87798.