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

 
We decided that the Plan does not have to pre-approve a foldable power operated vehicle (scooter). 
 
You asked the Plan to pre-approve the scooter. You say that this is needed due to not being able to walk 
straight. The Plan denied your request. The Plan says you should be checked by an expert to see that the 
equipment can be safely used. 
 
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 scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found that there are no 
neurological deficits identified on the exam. You are ambulatory. There is no evaluation showing necessity or 
capacity to use this device. You do not require this power scooter to manage self care in the 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 the scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a foldable power operated vehicle (scooter).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are necessary. The Plan 
denied your request. The Plan says the criteria for an LTACH admission has not been met. 
 
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 the enrollee is improving but still requires acute care services before transitioning to 
a lower level of care. The medical record does not indicate that the enrollee requires services that she is not 
currently receiving but that would be available at the LTACH facility. The coverage rules are not satisfied. The 
requested service cannot be recommended. 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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 80053 billed for date of service January 19, 
2023.  
 
You asked the Plan to pay for procedure code 80053. You say that you are an independent laboratory and do 
not have access to the physician's notes and records. The Plan denied your request. The Plan says the number of 
units billed exceeds the maximum allowed.  
 
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 80053 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. You did not address the need for 
additional units of this code at all in your appeal request. Based on this information, we decided that Medicare 
rules for coverage of procedure code 80053 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 80053 billed for date of service January 19, 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 requested SNF services are medically necessary. The Plan denied your request. The Plan says you do not require daily skilled therapies that can only be provided in an inpatient setting, and there are no 
daily skilled nursing needs as your current needs can be met at an alternative level of care.  
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued enrollment in the Heart Health Program. 
 
You asked the Plan to pre-approve continued enrollment in the Heart Health Program. You say that this service 
is medically necessary. The Plan denied your request. The Plan says the enrollee is no longer eligible for this 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 continued enrollment in the Heart Health Program have been met. No information was provided by the appellant to support this request. No 
clinical documentation was provided. Therefore, we decided that the Plan does not have to pre-approve 
continued enrollment in the Heart Health Program.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-rays provided on August 22, 2023. 
 
You asked the Plan to waive the copayment for the x-rays. You say that you feel it should be covered. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $35 copayment for the x-rays. 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 x-rays provided on August 22, 2023.
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 IRF care is needed to regain functional mobility. The 
Plan denied your request. The Plan says IRF care is not reasonable and 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 the complexity of the patient's nursing, medical, and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical records support a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT), thorax, diagnostic; with 
contrast material (71260) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a CT scan of the thorax. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the enrollee must use network providers to get medical care and services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a computed tomography (CT), thorax, diagnostic; with contrast material (71260) to be provided by an out-of-
network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on June 
30, 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. Therefore, we decided that the Plan does not have to pay for 
the emergency department (ED) services provided on June 30, 2023.
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 you disagree with the denial of the 
admission to a LTACH. The Plan denied your request. The Plan says these services can be provided at 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 the enrollee is presently receiving appropriate services in the acute care 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 81479-GZ billed for date of service July 25, 2022. 
 
You asked the Plan to pay for code 81479-GZ. You say that this testing detects allograft injury and/or rejection 
in lung transplant recipients and informs clinical decision-making. The Plan denied your request. The Plan says 
the modifier billed renders this code non-payable. The Plan must follow Medicare rules. Medicare rules say 
that any claim lines billed with the GZ modifier are automatically denied.  In this case, the code in dispute was 
billed with the GZ modifier. Therefore, we decided that the Plan does not have to pay for code 81479-GZ billed 
for date of service July 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics.  
 
You asked the Plan to pay for foot orthotics. You say that you believe these items are covered under the 
enrollee's plan. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot 
orthotics.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary for the enrollee's 
conditions. 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 Eliquis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient rehabilitation facility (IRF) admission and 
services provided from JUNE 06, 2023, through JUNE 19, 2023. 
 
You asked the Plan to pay for the IRF care. You say that the IRF stay was medically necessary. The Plan 
denied your request. The Plan says the IRF stay was not medically necessary for the enrollee. 
 
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 pay for the IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was medically stable and did not need PM&R physician supervision 3 
times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. During the IRF stay, there were no major medical problems identified or treated. The 
enrollee did not need the intensity of therapies in the IRF, consisting of at least 3 hours of therapy per day at 
least 5 days per week with multidisciplinary approach to daily therapy in an IRF. 
The enrollees mobility and ADLs were requiring very little assist, which could have been accomplished in 
lower intensity rehab setting. Therefore, the IRF stay was 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pay for the acute inpatient rehabilitation facility (IRF) admission and services provided from JUNE 06, 
2023, through JUNE 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network sleep study test provided on 
June 30, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network sleep study test. You say that you feel you have 
been getting the run around with this test. You have had to repeat it a number of times and feel you should not 
have to pay. 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 20% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 20% coinsurance for an in-network sleep study test. 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. The total you owe is $183.74 ($918.68 x 20% = 
$183.74). Therefore, we decided that the Plan does not have to waive the coinsurance for an in-network sleep 
study test provided on June 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
August 16, 2023, and billed with codes 87998 x13, 87653, and 87481. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this panel is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on August 16, 2023, 
and billed with codes 87998 x13, 87653, and 87481.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services, and an office visit provided on August 
22, 2023, to August 31, 2023. 
 
You asked the Plan to pay for home health services, and an office visit. You say that these 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 home health services, 
and an office visit provided on August 22, 2023, to August 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Volara system (E1399) and monthly supplies 
(A9999). 
 
You asked the Plan to pre-approve the Volara system. You say that medical records provided support the 
necessity of the requested services in dispute The Plan denied your request. The Plan says the system is 
considered investigative/experimental and is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file and Medicare rules. IPV in the home setting is not covered. There is insufficient reliable 
evidence in the form of high-quality peer-reviewed medical literature to establish the safety and efficacy or 
effects on health care outcomes. Based on this information, we decided that Medicare rules for coverage of the 
Volara system have not been met. Therefore, we decided that the Plan does not have to pre-approve the Volara 
system (E1399) and monthly supplies (A9999).