Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0835) and 
accessories (codes E1028, E1002, E2620, E0955, E1012, E2311, and E2605). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the DME is medically 
necessary. The Plan denied your request. The Plan says the DME is not medically necessary. 
 
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 durable medical equipment (DME). 
Our physician reviewer found you are able to use a manual wheelchair in your home to perform MRADLs.  
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0835) and 
accessories (codes E1028, E1002, E2620, E0955, E1012, E2311, and E2605).
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. 
 
You asked the Plan to pay for the office visit. 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 the office visit provided 
on February 15, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR) (33285).  
You asked the Plan to pre-approve insertion of an ILR. 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 must follow Medicare rules. Medicare rules say that cardiac event monitors are covered when specific 
criteria are met. 
 
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 insertion of an ILR. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient documentation to support the medical necessity for insertion of 
an implantable cardiac monitor (ICM) in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR) (33285).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for seven additional units of procedure code 99458 rendered on 
March 30, 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 records do 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. 
 
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 number of billed units is not 
supported. It appears that some of the logged time is phone tag rather than care time. The records do not 
adequately reflect that the services were medically necessary.  The records do not adequately reflect that the 
amount of time billed was actually provided, necessary or reasonable. 
 
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 seven additional units of procedure code 99458 rendered on March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care treatment provided on January 30, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for wound care treatment. You say that the assisted living facility is responsible to 
obtain prior authorization for all of their patients. The Plan denied your request. The Plan says the 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 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 wound care treatment provided on January 30, 
2023, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with DRG 374 rendered 
from August 5, 2022.  
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was changed from 374 to 375. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 374. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that there is not clear documentation of a formal assessment of nutritional status to support the secondary 
diagnosis of E43. The records more support DRG 375 based on the other comorbidities beyond cancer.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services billed with DRG 374 rendered from August 5, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar/sacral facet joint radiofrequency neurolysis 
(64635). 
 
You asked the Plan to pre-approve lumbar/sacral facet joint radiofrequency neurolysis. 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 an initial thermal radiofrequency ablation (RFA) of 
cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves is considered medically 
reasonable and necessary for patients who have had at least two (2) medically reasonable and necessary 
diagnostic MBBs, with each one providing a consistent minimum of 80% sustained relief of primary (index) 
pain (with the duration of relief being consistent with the agent used). 
 
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 lumbar/sacral facet joint radiofrequency 
neurolysis. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
records do not show that the enrollee has facet joint pain on physical exam. Also, there is no degree of 
functional improvement documented from previous injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar/sacral facet joint radiofrequency neurolysis have not been met. 
Therefore, we decided that the Plan does not have to pre-approve lumbar/sacral facet joint radiofrequency 
neurolysis (64635).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on January 
19, 2023. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary.  
The Plan denied your request. The Plan says this test is not FDA approved for use in the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on March 15, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for podiatry services. You say that you believed you were in-network. The Plan 
denied your request. The Plan says this 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 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 podiatry services provided on March 15, 2023, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on December 30, 2022, billed 
with procedure codes 72100 and 72070. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 72100 and 72070 is Radiologic examination, spine, 
lumbosacral; 2 or 3 views, and Radiologic examination, spine; thoracic, 2 views. 
 
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 imaging services provided. Our reviewer says that documentation does not support the billed codes. Our reviewer found medical documentation does not support 
that procedure 72100 and 72070 were performed, medical records only document that a Magnetic resonance 
imaging (MRI) was performed. 
 
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 imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on December 30, 2022, billed with procedure 
codes 72100 and 72070.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that a MyoPro orthosis is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says a MyoPro orthosis 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 pre-approve a MyoPro orthosis. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the requested device has not been shown to be superior to other standard treatments for the 
enrollee's medical condition. Studies do not indicate the MyoPro orthosis improves an individuals function or 
general health.  
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 MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro orthosis (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care treatment provided on December 12, 2022, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for wound care treatment. You say that the assisted living facility is responsible to 
obtain prior authorization for all of their patients. The Plan denied your request. The Plan says the 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 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 wound care treatment provided on December 12, 
2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ECG provided on February 28, 2023. 
 
You asked the Plan to waive the copayment for ECG. You say that you say the copayment should only be $15. 
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 $20 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $20 copayment for ECG. This item/service falls within the outpatient diagnostic 
tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for ECG provided on February 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on January 26, 2023, billed with 
procedure code 76706-26. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the diagnosis is inconsistent with the procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for a one-time ultrasound 
screening for abdominal aortic aneurysm (AAA) for beneficiaries who meet the required criteria.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services provided have not been met. This claim was billed with diagnosis code Z13.6 
which does not meet the requirements for the procedure. Therefore, we decided that the Plan does not have to 
pay for imaging services provided on January 26, 2023, billed with procedure code 76706-26.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an office visit provided on January 12, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary. The Plan denied your 
request. The Plan says that no payment was allowed for this service. 
 
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. The Plan has not provided any reasoning for why payment could not be made for 
the services. Without this information, the denial cannot be verified. Therefore, we decided that the Plan has to 
pay for an office visit provided on January 12, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on January 10, 2023, billed with 
procedure code 93306. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 indicates 
that the two conditions cannot occur together. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the imaging services provided have not been met. The billed service has been reported with 
diagnosis codes I51.9 and I08.3, which are subject to an Excludes1 note. Therefore, we decided that the Plan 
does not have to pay for imaging services provided on January 10, 2023, billed with procedure code 93306.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 rendered on 
February 14, 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 records do 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 the denied codes is: 
 
CPT 96365: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour  
CPT 96366: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour 
(List separately in addition to code for primary procedure) 
 
CPT 96521: 
 
Refilling and maintenance of portable pump 
 
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 CPT codes 96365 and 96366 are 
not supported. The record states that a continuous insulin treatment guided by glucose measurements was 
performed. There is a more specific code to report this procedure. CPT code 96521 is not supported. The record 
states that the infusion was given in the office setting, not through durable medical equipment (DME). There is 
a more specific way to report the procedures performed. 
 
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 codes 96365, 96366, and 96521 rendered on February 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) scan (78815). 
 
You asked the Plan to pre-approve a PET-CT scan. You say that a PET-CT scan is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says a PET-CT scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 a PET-CT scan. Our reviewer says that 
a PET-CT scan is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has suspicious findings in the urinary bladder on a recent CT urogram; however, the bladder is not 
well distended and not completely evaluated. The Bosniak type 3 renal mass is not definitely malignant and 
PET-CT should not be used to make a malignant diagnosis. 
 
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 PET-CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography 
(CT) scan (78815).