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

 
We decided that the Plan does not have to pre-approve a Group 1 standard power operated vehicle (power 
scooter) (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that you cannot walk and are using your husband's 
old scooter that is outdated and going dead. You also say that you are unable to move without it and will not be 
able to do your daily activities during the day.  The Plan denied your request. The Plan says based on Medicare 
guidelines, the power scooter requested does not meet the requirements for approval. 
 
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 scooter. Our reviewer says that 
this request is not medically necessary. Our physician reviewer found you have arthritis in your knees. Our 
reviewer also found that the record does not address your functional capacity nor the adequacy and necessity of 
the requested scooter for your home. 
 
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 scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Group 1 standard power operated vehicle (power scooter) (K0800).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 26, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was 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 laboratory services 
provided on April 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 26989 rendered on July 27, 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 there is a more appropriate code to describe the services 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. 
 
In this case, the CPT Code Manual definition of code 26989 is ""Unlisted procedure, hands or fingers." 
 
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 documentation does not 
support that CPT 26989: under other procedures on the hands or fingers was rendered in this case. The enrollee 
was being treated for palmar fascial fibromatosis (Dupuytrens). The documentation does support that he has undergone a needle aponeurotomy on this date with medications noted as 10mL lidocaine 10mg/mL and 
manipulation. However, detailed documentation is not evident as to why the CPT (current procedural 
terminology) 26341 was not used to bill for this procedure. CPT 26341 is manipulation, palmar fascial cord, 
post enzyme injection, single cord. This more specifically related to the procedure than the general code of 
CPT 26989 under other procedures on the hands or fingers. Therefore, while there is indication of a 
hand/finger procedure having been performed, the appropriate code was not utilized.  
 
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 26989 rendered on July 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94060 rendered on May 23, 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) code 94060 XU (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 94060 is ""Bronchodilation responsiveness, spirometry as 
in 94010, pre- and post-bronchodilator administration." 
 
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 according to the medical 
records, the test performed on May 23, 2023 was spirometry without bronchodilator administration. The quality of the test was poor, and the results were normal. There is no evidence in the report of a bronchodilator 
challenge. The coding of bronchodilation responsiveness is incorrect. 
 
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 94060 rendered on May 23, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 5 units of procedure code Q0092 rendered on August 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 billed number of units is not supported by the records as both provided and medically 
necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code Q0092 is 4. The MAI value for this code is 3. You billed 5 units of this 
code, exceeding the MUE.  
 
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 Q0092. Our reviewer says that the services 
at issue in this case are not supported by the medical records. Our reviewer found that on August 14, 2023, a 
bilateral four view wrist series was done. As such, one unit of setup would be allowed for Q0092. In addition, a 
facial bone series - CPT 70150 - was done, with one unit of setup. Next, two units of a two view right forearm 
series was done. Medicare does not allow two codes for Q0092 for a repeat of a single series CPT code. If one 
presumes the intention was to bill for a bilateral forearm series still only one Q0092 code would be allowed. 
Additionally, the medical necessity or indication for none of these exams was included in the dictations. 
Radiographic exams without a dictated indication or symptom should not be reimbursed.  
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Q0092 have not been met. Therefore, we decided that the Plan does not have to 
pay for 5 units of procedure code Q0092 rendered on August 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on August 09, 2023, to 
August 10, 2023. 
 
You asked the Plan to pay for the outpatient services. You say that the services should be covered The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the outpatient services 
provided on August 09, 2023, to August 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on July 26, 2023. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you were told that the cost-share for 
the procedure would be $90 and you were not expecting to pay $120 for the services. 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 $120 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $120 copayment for the CT scan. 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 the CT scan provided on July 26, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99284) rendered 
on May 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 CPT 99284 was billed and 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 enrollee presented to the 
emergency department with a left hand injury after a bicycle accident. The physical examination showed 
swelling, tenderness and an abrasion on the left hand; radiologic studies were negative for fracture or 
dislocation. There were no other radiologic or laboratory studies documented and no other documented injuries 
or acute medical conditions. The enrollee was discharged to home with a recommendation to use Tylenol and 
follow-up with his primary care provider. The provided records in this case do not document 2 out of 3 of 
multiple diagnoses or management options, a moderate amount and complexity of data reviewed and moderate 
risk of complication. 
 
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 room services (procedure code 99284) rendered on May 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99379 billed for date of service August 20, 
2023. 
 
You asked the Plan to pay for procedure code 99379. You say that these services were provided in good faith 
and were medically necessary. The Plan denied your request. The Plan says procedure code 99379 is 
considered bundled and not separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99379 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99379 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99379 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99379 billed for date of service August 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 27, 2023. 
 
You asked the Plan to pay for an office visit. You say that this is supported in the records. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on September 27, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee cannot be safely discharged home. The 
enrollee lives alone and cannot climb their stairs to the second floor. The Plan denied your request. The Plan 
says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device. 
 
You asked the Plan to pre-approve a MyoPro orthotic device. You say that the MyoPro is supported as an 
appropriate intervention and is reasonably and medically necessary as recognized by medical communities and 
key opinion leaders in rehabilitation. The Plan denied your request. The Plan says a MyoPro 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 a MyoPro orthotic device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro Orthosis is not known to be effective, based on scientific evidence, 
professional standards, and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for this patient's stroke condition or in widespread use for this patient's condition based on scientific 
evidence. Our reviewer found that there is insufficient evidence in the literature that the MyoPro Orthosis will 
improve the long-term outcomes for this patient. Our physician reviewer also found that there is insufficient 
evidence in the literature that this device will increase participation in bimanual activities.  
 
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 orthotic device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro orthotic device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Buprenorphine-Naloxone. 
 
You asked the Plan to pre-approve the medication. You say that the requested drug is medically necessary to 
treat the enrollee's opioid dependence. The Plan denied your request. The Plan says the medication is not 
covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Buprenorphine-Naloxone.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vancomycin hydrochloride (HCL). 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve vancomycin hydrochloride 
(HCL).  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on July 6, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says the items were not 
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 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 durable medical equipment (DME) provided 
on July 6, 2023, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service July 25, 
2023, to August 23, 2023. 
 
You asked the Plan to pay for the billed services. You say that the dates on the claim were during active 
coverage. The Plan denied your request. The Plan says an NOA was not submitted. 
 
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 looked at the file and the rules. The documentation in the case file does not show that a timely-filed NOA 
was submitted to the Plan as required. Based on this information, we decided that Medicare rules for coverage 
of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for the home 
health care billed for dates of service July 25, 2023, to August 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 22, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was 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 laboratory services 
provided on March 22, 2023.