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 (K0823), 
detachable armrest (E0973), retractable or removable mounting hardware for joystick (E1028), and U1 sealed 
lead acid battery (E2365). 
 
  You asked the Plan to pre-approve a group 2 standard power wheelchair and additional items and accessories. 
You say that you have been in a powered wheelchair since 2017 or 2018. You also say that you are immobile 
without a powered wheelchair. The Plan denied your request. The Plan says the documentation indicates that 
your needs can be met with a power scooter and the physician order is for a power scooter. The Plan says that 
therefore, you do not meet the Medicare medical necessity criteria for the requested power wheelchair. 
 
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 group 2 standard power wheelchair 
and additional items and accessories. Our reviewer says that the group 2 power wheelchair is not medically 
necessary. Our physician reviewer found there is limited documentation regarding your level of mobility and 
function as well as your motor strength in the upper and lower extremities. You are noted to be using a power 
scooter or group 1 power mobility device for mobility and performing your daily activities. Our reviewer found 
that the clinical documentation indicates that it is in disrepair and requires replacement. Our physician reviewer 
also found that there is no mobility evaluation provided in terms of why a higher-level mobility device such as 
a group 2 power mobility device is required for your mobility needs and performing daily 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 group 2 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 standard power 
wheelchair (K0823), detachable armrest (E0973), retractable or removable mounting hardware for joystick 
(E1028), and U1 sealed lead acid battery (E2365).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99292 billed for date of service May 13, 
2023. 
 
You asked the Plan to pay for procedure code 99292. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 99292 is: Critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service). 
 
We find that CPT code 99292 is not supported in the medical record. Specifically, the case record indicates that you also reported code 99291, which describes 30 to 74 minutes of critical care. The case record documents 
that the Plan has paid for code 99291. The provided medical records do not support an additional 30 minutes of 
critical care. Based on this information, we decided that Medicare rules for coverage of procedure code 99292 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99292 billed 
for date of service May 13, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 17, 2023, to 
April 15, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you have reported the services at 
issue correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that he home health agency (HHA) enters a date of admission 
matching the From date on the first period of care in an admission. 
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA as required. Based on this information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for 
the home health services provided from March 17, 2023, to April 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on April 27, 2023. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says an eye refraction 
is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules state that Medicare does not pay for procedures performed in 
the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered 
even when done in connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when 
done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided 
that the Plan does not have to pay for an eye refraction provided on April 27, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a facet joint injection. 
 
You asked the Plan to pre-approve a facet joint injection. You say that the enrollee requires an injection to 
improve their current medical condition. The Plan denied your request. The Plan says that the procedure 
requested is 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 a facet joint injection. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the disc bulge is asymptomatic as there are no radicular signs or symptoms. The 
imaging clearly shows pathology that corresponds to the physical exam. 
 
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 facet joint injection have been met. Therefore, we decided that the Plan has to 
pre-approve a facet joint injection.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a capsule endoscopy provided on April 10, 2023. 
 
You asked the Plan to pay for the capsule endoscopy. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the service provided requires prior authorization for non-contracted 
providers. No authorization has been obtained. 
 
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 a capsule endoscopy provided on April 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fifty (50) additional non-emergent routine transportation 
trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you receive dialysis 
three days a week and you are requesting additional rides for future appointments. The Plan denied your 
request. The Plan says additional trips would exceed your benefit limit. 
 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 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. The records show that you have used 
twenty-four (24) one-way transportation trips out of the allowed seventy-two (72) one-way trips approved. 
Once 72 trips are used, the benefit will be exhausted. Based on this information, we decided that the Plans 
rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve fifty (50) additional non-emergent routine transportation trips (A0120).
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 meets Medicare criteria and will benefit 
with Acute Inpatient Rehab that cannot be accomplished at a lower level of 
care. The Plan denied your request. The Plan says the enrollee's records do not show the need for intensive 
services consisting of 3 hours of daily therapies for rehabilitation. The Plan says that the services needed may 
be provided safely in a lower 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.  
 
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: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) G0480 and 80307. We 
decided that the Plan does not have to pay for the services described by procedure code(s) 83789.  
 
You asked the Plan to pay for drug testing services (G0480, 80307 and 83789) provided on Mary 12, 2023. 
You say that these services were necessary and are supported in the medical record. The Plan says that code 
83789 is not separately payable, and there is no list of specific drugs requested for testing to substantiate the 
other codes requested. 
 
We decided that the Plan has to pay for the services described by procedure code(s) G0480 and 80307.  
 
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. Specifically, the Plan states that a list of drugs requested for testing was not 
included in the records. However, the records provided include a list with a detailed custom panel which is 
signed by this provider and is on file with this laboratory as the requested panel. The drugs tested align with 
those requested in this panel. The Plans denial is not substantiated. Therefore, we decided that the Plan has to 
pay for the services described by procedure code(s) G0480 and 80307.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
83789. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Based on this information, we decided that Medicare rules for coverage of the services 
described by procedure code(s) 83789 have not been met. Therefore, we decided that the Plan does not have to 
pay for the services described by procedure code(s) 83789. 
 
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 physician services (99223) provided on January 30, 2023. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 physician services have been met. 
Specifically, insufficient clinical documentation was provided for review to support the code billed. Therefore, 
we decided that the Plan does not have to pay for physician services (99223) provided on January 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee needs the home ventilator to 
keep him from returning to the hospital. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for approval of a ventilator. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has obesity 
hypoventilation syndrome (OHS) and obstructive sleep apnea (OSA) with associated chronic respiratory failure 
and studies show benefit from BiPAP. The enrollee does not have a failure of BiPAP therapy and hence, the 
home ventilator is not required. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable for transfer 
requiring prolonged intensive skilled services that are not available at a lower level of care. The Plan denied 
your request. The Plan says the enrollee's records do not show the need for continued treatments and care that 
can only be given in a hospital setting. The Plan says when the enrollee is ready to leave the hospital that the 
services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not available at the current health care setting being offered by the health plan. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you are requesting reconsideration because 
a BiPAP device will not meet the enrollee's medical needs. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for approval of a ventilator. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee requires a repeat sleep 
titration study to determine if BiPAP therapy or a ventilator is needed. The enrollee is compliant with CPAP 
and if upscale of the mode of therapy is required, a sleep titration study is needed. Hence, the enrollee does not 
qualify for home ventilator or BiPAP with the documentation provided. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for psychotherapy provided from February 2, 2023, to 
April 19, 2023. 
 
You asked the Plan to reimburse you for the psychotherapy. You say that you have to see this provider on a 
continual basis to resolve your fear/anxiety due to post traumatic stress disorder. You say that you have a PPO 
plan that allows coverage to see providers with less reimbursement. The Plan denied your request. The Plan 
says this provider is not part of the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
psychotherapy provided from February 2, 2023, to April 19, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided March 22, 2022, through 
March 30, 2022.  
You asked the Plan to pay for the home health services. You say that the Patient-Driven Groupings Model 
(PDGM) billed is supported.  The Plan denied your request. The Plan says the PDGM billed is not supported.  
 
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 home health services. Our physician 
reviewer found the Health Plans denial should be upheld. The enrollee does not appear to have been 
homebound, as evidenced by her orthopedic appointment. The enrollee did not have documented home health 
(HH) physical therapy (PT) needs. The enrollee was functioning at a level commiserate with a lower level of 
care. The HH PT services were not medically necessary or reasonable. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided March 22, 2022, through March 30, 2022.