Persius/hicric huggingface dataset:
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 wheelchair accessory. You say that your current wheelchair has this 
feature, and it was previously approved. The Plan denied your request. The Plan says documentation does not 
support that all other alternatives for mobility have been exhausted and that a power seat elevator is the only 
option. 
 
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 wheelchair accessory. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you are noted to have low back pain and amyotrophic lateral sclerosis. You are noted 
to have 4-5/5 motor strength in the upper and lower extremities. Your level of function in terms of performing 
daily activities and transfers is not indicated. There is no mobility evaluation provided regarding your level of 
mobility and if you are a full-time power wheelchair user. The guideline policy requires that you be dependent 
with transfers or perform weight being transfers to and from a power wheelchair and that daily activities can be 
performed without caregiver assistance. This information is not provided. Therefore, the power seat elevator 
(E2300) is not medically 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 a wheelchair accessory have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power seat elevation system (E2300).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on May 
23, 2023. 
 
You asked the Plan to pay for the ED services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says Medicare payment cannot be made to this type of 
provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on May 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 28, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were billed incorrectly. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on April 26, 2023. 
 
You asked the Plan to pay for the podiatry services. You say that this service was billed correctly. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for podiatry services provided on April 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on April 28, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the billed diagnosis codes are not appropriate. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the claim was billed with diagnosis codes that 
exclude one another. Therefore, we decided that the Plan does not have to pay for the anesthesia services 
rendered on April 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 6, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The referring provider 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 laboratory services provided on March 6, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on June 21, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were billed incorrectly. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on June 21, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary for you. The 
Plan denied your request. The Plan says the services you need can be provided safely in other settings. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found your condition is in fact complex and fragile, and there is adequate reason to expect that you will 
participate in and benefit from IRF-level services to include at minimum PT, OT, physician oversight of 
polypharmacy, and case manager coordination of any additional services that might be needed to make a 
sustainable return home versus explore other more sustainable residential environments, as well as avoid 
further preventable readmissions to the acute hospital. Therefore, the requested inpatient rehabilitation facility 
admission is approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (0315U) provided on April 24, 2023. 
 
You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that MolDX will only cover and reimburse tests that 
demonstrate analytical and clinical validity, and clinical utility at a level that meets the Medicare reasonable 
and necessary requirement. 
 
We looked at the file and Medicare rules. DecisionDx-SCC is not listed as a covered test on the MolDx 
registry. Based on this information, we decided that Medicare rules for coverage of the lab testing have not 
been met. Therefore, we decided that the Plan does not have to pay for lab testing (0315U) provided on April 
24, 2023.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve Quantitative Calcium Scoring (75571). 
 
You asked the Plan to pre-approve Quantitative Calcium Scoring . You say that the service was medically 
necessary. The Plan denied your request. The Plan says that the service was not medically necessary. 
 
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 Quantitative Calcium Scoring . Our 
reviewer says that the requested service is considered medically reasonable and necessary in this case. Our 
physician reviewer found given the patient's risk factors this test was both 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 Quantitative Calcium Scoring  have been met. Therefore, we decided that the 
Plan has to pre-approve Quantitative Calcium Scoring (75571).  
 
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 motor upgrade (K0108), cell phone holder (K0108), 
Smart track assistive driving package (K0108), Power tech sigma (K0108), and dimensional pad (K0108). 
 
You asked the Plan to pre-approve a motor upgrade, cell phone holder, Smart track assistive driving package, 
Power tech sigma, and dimensional pad. You say that you would like the provided documentation to be 
reconsidered for the wheelchair and accessories that are medically necessary to meet the patient's current needs. 
The Plan denied your request. The Plan says the motor upgrade, cell phone holder, Smart track, and 12-volt 
power supply do not serve a medical purpose, and cannot be covered as they are not reasonable and necessary 
per Medicare criteria. The Plan says that the seat cushion (K0108) is incorrectly coded and cannot be approved. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.    
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 motor upgrade, cell phone holder, 
Smart track assistive driving package, Power tech sigma, and dimensional pad. Our reviewer says that based on 
the medical records provided there is no documentation that the motor upgrade (K0108), cell phone holder 
(K0108), Smart track assistive driving package (K0108), Power tech sigma (K0108), and dimensional pad 
(K0108) at issue in this case meet all Medicare criteria for medically reasonable and necessary for the patient. 
Our physician reviewer found the provided records in this case do not document that the requested accessories 
are needed for a medical purpose to assist in participation in mobility related activities of daily living such as 
toileting, feeding, grooming, and bathing in customary locations within the home. 
 
We looked at this physician's review, the file, and Medicare rules. The items at issue in this appeal do not serve 
purposes that are primarily medical in nature. These items are available to the general public and would be 
helpful even to those who are not sick or injured. Based on this information, we decided that Medicare rules for 
coverage of a motor upgrade, cell phone holder, Smart track assistive driving package, Power tech sigma, and 
dimensional pad have not been met. Therefore, we decided that the Plan does not have to pre-approve a motor 
upgrade (K0108), cell phone holder (K0108), Smart track assistive driving package (K0108), Power tech sigma 
(K0108), and dimensional pad (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 14, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services cannot be 
verified.  
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 rules also say that the physician must 
clearly document, in the medical record, his or her intent that the test be performed. 
 
In this case, the CPT Code Manual definition of code P9603 is "Travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated miles actually travelled". 
 
We find that CPT code P9603 is not supported in the medical record. Specifically, the records provided do not 
show the prorated miles actually travelled to support this code and units. Based on this information, we decided 
that Medicare rules for coverage of code P9603 have not been met. 
 
We also find that the documentation submitted does not contain a valid physician order or lab requisition for 
the specific testing provided in this case. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on February 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization. 
 
You asked the Plan to pre-approve genicular artery embolization. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is experimental, investigation or unproven. 
 
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 genicular artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered an experimental/investigational procedure. It is the 
subject of ongoing clinical trials. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization.
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 would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission 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 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.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 19499 rendered on August 9, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code - 19499- LT (1 unit) 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 19499 is "Unlisted procedure, breast." 
 
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 procedure report describes a 
bilateral mastectomy. The medical records do not include documentation to verify an unlisted procedure code. 
Because unlisted and unspecified procedure codes do not describe a specific procedure or service, it is necessary to submit supporting documentation when filing the claim or on request. 
 
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 19499 rendered on August 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (29999) provided on April 6, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed 
without the appropriate modifier. 
 
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 find that payment for CPT code 29999 is not supported in the medical record. Specifically, code 29999 was 
billed without the required anatomic modifier. 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 the 
services (29999) provided on April 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (G0480, 80307 and 83789) provided on 
June 6, 2023. 
 
You asked the Plan to pay for drug testing. You say that these services were medically necessary and should be 
paid. The Plan denied your request. The Plan says code 83789 is not separately payable, and codes G0480 and 
80307 are not supported in the records provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that providers performing validity testing on urine specimens utilized for drug testing should not separately bill the validity 
testing. 
 
In this case, the CPT Code Manual definition of code 80307 is drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures. The CPT Code Manual definition of code G0480 is drug test(s), 
definitive, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing services have not been met. Specifically, the records provided do not include test 
results for any presumptive or screening drug tests. Without these results, we cannot verify the services were 
provided as billed. Code G0480 is not supported, as the records show that drugs from more than 7 classes were 
tested. There is a more appropriate code to report the services provided. In addition, we find that the testing 
described by code 83789 is not separately payable. Therefore, we decided that the Plan does not have to pay for 
drug testing services (G0480, 80307 and 83789) provided on June 6, 2023.