Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the specialist office visit and the biopsy 
procedure provided on April 11, 2023. 
 
You asked the Plan to reduce the copayment for the specialist office visit and the biopsy. You say that you are 
being double charged for the visit. 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 a $35 
copayment per visit, to an in-network specialist. 
 
 
 You have been asked to pay $34.59, which is less than the standard copayment for the specialist office visit. 
You have also been asked to pay a $35 copayment for the biopsy. These items/services fall within the 
physician/practitioner services, including doctor's office visits 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 reduce the copayment for the specialist office visit and the biopsy procedure provided on April 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says an epidural 
steroid injection is not medically necessary.   
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that the enrollee has a history of 
chronic low back pain due to lumbar spinal stenosis without neurogenic claudication. The enrollee also has 
symptoms into her legs that are affecting their ability to walk. However, there is no documentation of lumbar 
radiculopathy, radicular pain, neurogenic claudication due to disc herniation, osteophyte, osteophyte 
complexes, sever degenerative disc disease, producing foraminal or central spinal stenosis. Therefore, the 
enrollee does not meet the LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0823) with a battery, 
manual swingaway, and an adjustable arm height option.  
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that these items are medically 
necessary. The Plan denied your request. The Plan says the coverage criteria has 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.  
 
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 power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the enrollee is 
not at high risk for skin breakdown, does not use a catheter intermittently, does not have spasticity, and does 
not require an alternative means of managing power drive controls. As the power wheelchair base is not 
medically necessary, the requested accessories are not covered. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 2 power wheelchair (K0823) with a battery, manual 
swingaway, and an adjustable arm height option.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor foot/ankle feature (L5973) and a 
prosthetic covering (L5962). 
 
You asked the Plan to pre-approve the microprocessor foot and covering. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says the enrollee does not meet the criteria for a 
microprocessor foot, and the enrollee does not need an extra prosthetic covering. 
 
The Plan follows Medicare rules. Medicare rules say that a microprocessor foot/ankle is covered when all the 
criteria listed in the Medicare rules section are met. The rules also say a protective outer surface covering is 
covered when a beneficiary who has special needs for protection against unusually harsh environmental 
situations where it is necessary to protect the lower limb prosthesis 
 
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 microprocessor foot and covering. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the medical 
necessity of the microprocessor foot remains unclear for standard activity. There is a theoretical advantage of 
less energy during ambulation. The medical necessity for the microprocessor ankle for this enrollee is not 
evident as it is unclear how standard prostheses have failed to meet her needs. Per LCD L33787, the specific 
indication for a microprocessor must be supplied. The enrollee does not require a protective cover as she is not 
in harsh environments. 
 
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 microprocessor foot and covering have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a microprocessor foot/ankle feature (L5973) and a prosthetic 
covering (L5962).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says the house does not have access for this power-operated vehicle. 
 
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.  
 
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 item. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that the documentation available for review does not support that you require a power mobility device to accomplish 
mobility-related self-care tasks in the home. There is no indication you are unable to use an alternative assistive 
device. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a group 1 standard power operated vehicle.
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 the need for care in an 
IRF.  The Plan denied your request. The Plan says the enrollee does not have complex rehabilitation, medical, 
and nursing needs. The Plan says that the enrollee's needs can be met at an alternate 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 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 
was admitted for pneumonitis. The enrollee's medical problems are stable. There are no complex nursing or 
rehabilitation needs. 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 this 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 rendered on February 9, 2023. 
 
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) 87640 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 87640 is "Staphylococcus aureus, amplified probe technique." 
 
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 laboratory report documents 
staphylococcus aureus, methicillin resistant, amplified probe technique was performed.  In this case, CPT 
87641 would be reported. Modifier 59 distinct procedural service cannot be verified in the documentation 
submitted for review. 
 
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 procedure code 87640 rendered on February 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the durable medical equipment purchased 
from January 8, 2023, to January 29, 2023. 
 
You asked the Plan to provide reimbursement for the durable medical equipment. You say that you are 
requesting reconsideration for reimbursement of the items purchased from Amazon. The Plan denied your 
request. The Plan says that these items are not covered by Medicare. 
 
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. 
 
A 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 provide reimbursement for the durable medical 
equipment purchased from January 8, 2023, to January 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 7, 2023. 
 
You asked the Plan to pay for the office visit. You say that the patient is homebound due to COVID-19, and he 
could not leave his house to go to a provider that is in-network. You say the services were medically necessary. 
The Plan denied your request. The Plan says with the information we have, we cannot determine how the 
member came to the servicing provider, whether the services were performed as billed, or whether the services 
are medically necessary. 
 
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 office visit have been met. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on February 7, 2023.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve speech therapy (ST) services. 
 
You asked the Plan to pre-approve the therapy services. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says that the requested services are not medically reasonable 
and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that the services are medically necessary. Our physician reviewer found the requested speech therapy is 
generally accepted as a specific and effective therapy for the enrollees impaired communication, processing, 
and memory due to a right sided middle cerebral artery (MCA) stroke. He received speech therapy in acute 
inpatient rehabilitation and continues to require it on an outpatient basis. This can only be provided by a skilled 
speech therapist. 
 
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 therapy services have been met. Therefore, we decided that the Plan has to 
pre-approve speech therapy (ST) services.  
 
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 an office visit provided on February 1, 2023. 
 
You asked the Plan to pay for the office visit. You say that you were having severe back pain and needed to see 
a doctor and you were unaware the provider billed code 99213 and this wasnt covered. The Plan denied your 
request. The Plan says the only chiropractic service Medicare covers is manual manipulation of the spine to 
correct a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual 
manipulation is appropriate treatment. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit provided on February 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services: medical examination and 
evaluation provided on February 23, 2023. 
 
You asked the Plan to pay for ophthalmological services: medical examination and evaluation. You say that the 
services were medically necessary. The Plan denied your request. The Plan says that the Plan requires 
utilization of network providers when possible and available and requires authorization for certain services. No 
medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been 
documented. 
 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 ophthalmological services: medical examination and evaluation 
provided on February 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional routine transportation trips. 
 
You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your 
request. The Plan says the member has used all of their one-way trips for this calendar year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a maximum of 22 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine foot care. 
 
You asked the Plan to pre-approve the routine foot care. You say that routine foot care is medically necessary. 
The Plan denied your request. The Plan says routine foot care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pre-
approve are routine foot care services. Based on this information, we decided that Medicare rules for coverage 
of the routine foot care have not been met. Therefore, we decided that the Plan does not have to pre-approve 
routine foot care.
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 enrollee has complex needs that continues to 
require daily physician oversight provided at an IRF. The Plan denied your request. The Plan says the enrollee 
does not meet the Medicare criteria for an IRF admission. 
 
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 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency services (procedure code 99284) rendered on 
March 17, 2023. 
 
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 the claim was downcoded to CPT 99283. 
 
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 99284 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making." 
 
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 documented history and 
physical examination is not detailed. The medical decision making of not of moderate complexity, and the 
presenting condition was not of either moderate or high severity. 
 
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 emergency services (procedure code 99284) rendered on March 17, 2023.