Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (97530, 97535) provided on February 1, 
2023 to February 27, 2023. 
 
You asked the Plan to pay for the therapy services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says coverage criteria has 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. 
 
We find that CPT codes 97530, & 97535 are not supported in the medical record. Specifically, the services 
were performed by a therapy assistant but were not billed using the required CQ modifier. Based on this 
information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, 
we decided that the Plan does not have to pay for therapy services (97530, 97535) provided on February 1, 
2023 to February 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the eCoin device.  
 
You asked the Plan to pre-approve the eCoin device. You say that denial of this procedure is without any 
clinical basis, nor is it supported by clear and ambiguous language contained in the certificate of coverage or 
summary Plan description. The Plan denied your request. The Plan says the requested eCoin device is 
investigational/experimental. 
 
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 the eCoin device. Our reviewer says 
that the requested eCoin device is not considered medically reasonable and necessary. Our physician reviewer 
found that the provided medical records and review of the current peer-reviewed medical literature do not 
document that use of the eCoin device has been shown in controlled studies in a CMS-approved journal to result in long term health benefits in patients with urinary urge incontinence. The provided records include 
several open label, single arm, manufacturer sponsored studies of the device; additional controlled, unbiased 
study is needed to validate any benefit of the procedure and the device, and to compare it to other 
interventions.  
 
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 eCoin device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the eCoin device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service May 21, 
2023 to June 17, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service May 21, 2023 to June 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation (64635). 
 
You asked the Plan to pre-approve the service. You say that the radiofrequency ablation is medically necessary. 
The Plan denied your request. The Plan says the radiofrequency ablation 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 the service. 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 experimental therapy due to the wide variation in efficacy reported in the peer 
reviewed literature. Therefore, the request is deemed not 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the radiofrequency ablation (64635).
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 the services are medically necessary for the enrollee 
to regain their maximum function. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for admission to an IRF. 
 
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 the medical record overall significantly complies with the various documentation requirements for IRF 
admission. The beneficiarys condition is complex, fragile, but stable enough for discharge. There is every 
reason to expect that the enrollee will participate in and benefit from services to include at minimum of 
physical and occupational therapy, physician oversight polypharmacy, and case manager coordination of any 
additional services that might be needed to make a sustainable return home as well as avoid 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection (62321). 
 You asked the Plan to pre-approve the injection. You say that an epidural steroid injection is medically 
necessary. The Plan denied your request. The Plan says that an epidural steroid injection is not 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 the injection. Our physician reviewer 
found the enrollee has a complete history and physical exam without noted interval change. The request is 
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 the injection have been met. Therefore, we decided that the Plan has to pre-
approve an epidural steroid injection (62321).  
 
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 the Cxbladder test (0013M) provided on September 28, 
2022. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0013M) provided on September 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing care services. 
 You asked the Plan to pre-approve home health services. You say that additional home health care is medically 
necessary.  The Plan denied your request. The Plan says the enrollee does not currently require registered nurse 
visits in the home. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee is 
noted to be able to check his blood sugar and has been educated regarding his medications, has not recently 
been hospitalized. The enrollee may require some degree of oversight and supervision but does not have skilled 
nursing care needs. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skilled nursing care services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the medical services provided from March 10, 
2023, to April 6, 2023, by the out-of-network providers. 
 
You asked the Plan to reimburse you for the medical services. You say that you need to be reimbursed for the 
services that you received. The Plan denied your request. The Plan says there were no itemized receipts or 
complete medical records provided to support that the services should be paid. 
 
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 medical services have been met. 
Specifically, complete medical records, nor an itemized bill, were provided to show that there were services 
provided and should be paid. Therefore, we decided that the Plan does not have to reimburse you for the 
medical services provided from March 10, 2023, to April 6, 2023, by the out-of-network providers.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for each office visit and drug injection 
provided from May 24, 2023, to June 7, 2023. 
 
You asked the Plan to waive the cost sharing for each office visit and drug injection. You say that you asked 
each visit and were told there was no copayment. 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 $25 
copayment for specialist office visits. Your contract with the Plan also clearly says that you must pay 20% 
coinsurance for Medicare Part B drugs. 
 
Date of Service Code Allowed Amount Copayment Coinsurance 
May 24, 2023 96365 $66.91 $25 - 
May 24, 2023 J1756 $40 - $8 
May 31, 2023 96365 $66.91 $25 - 
May 31, 2023 J1756 $40 - $8 
June 7, 2023 96365 $66.91 $25 - 
June 7, 2023 J1756 $40 - $8 
Total $99 
 
You have been asked to pay a $25 copayment for each office visit. This item/service falls within the 
physician/practitioner services benefit category. You have also been asked to pay 20% coinsurance for each 
drug injection. This item/service falls within the Medicare Par B drugs 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 cost sharing for each office visit and drug injection provided from May 24, 2023, to 
June 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy provided from February 21, 2023, to 
April 25, 2023. 
 
You asked the Plan to pay for infrared therapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says infrared therapy is considered not reasonable and necessary by Medicare 
and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary under section 
1862(a)(1)(A) of the Social Security Act (the Act). We looked at the file and Medicare rules. Medicare says that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary. Therefore, we decided 
that the Plan does not have to pay for infrared therapy provided from February 21, 2023, to April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on April 08, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you say that no services were 
performed on this date of service. 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 $50 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $50 copayment for an office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 an office visit provided on April 08, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient home visit, and debridement of nails provided 
on February 23, 2023. 
 
You asked the Plan to pay for a new patient home visit, and debridement of nails. 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 a new patient home 
visit, and debridement of nails provided on February 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair (K0856) and 
additional items and accessories (codes E0955, E1002, E1028, E2300, E2311, E2361, E2603, K0040, and 
K0108). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that you cannot walk. You also say that everywhere you go, someone has to push you, and you have 
never had a power wheelchair. The Plan denied your request. The Plan says you do not have a qualifying 
diagnosis causing mobility limitation for which a K0856 group 3 power wheelchair is medically needed. 
 
 
 
 
 The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or 
congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 
standard power wheelchair (K0856) and additional items and accessories (codes E0955, E1002, E1028, E2300, 
E2311, E2361, E2603, K0040, and K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Ultralight therapy system provided on May 22, 2023. 
 
You asked the Plan to pay for the Ultralight therapy system. You say that the Ultralight therapy system is 
medically necessary. The Plan denied your request. The Plan says there is no indication of intractable psoriasis, 
as there is no documentation for treatment of psoriasis, or even any indication the enrollee has been seen by a 
dermatologist. There are also no other factors that justify treatment at home rather than alternative sites, like a 
clinic or the hospital. 
 
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 pay for the Ultralight therapy system. Our reviewer 
says that the requested Ultralight therapy system is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee with bilateral shoulder pain. The enrollees orthopedist placed 
an order for ultraviolet (UV) phototherapy. The enrollees medical record does not have any indication of a 
diagnosis of psoriasis. The requested system does not meet Medicare coverage criteria. 
 
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 Ultralight therapy system have not been met. Therefore, we decided that the 
Plan does not have to pay for the Ultralight therapy system provided on May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunization provided on July 12, 2023. 
 
You asked the Plan to pay for the immunization. You say that you are requesting reconsideration of the denied 
claim. 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 immunization 
provided on July 12, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography, soft tissue neck; with contrast 
material(s) provided on June 27, 2023. 
 
You asked the Plan to pay for computed tomography, soft tissue neck; with contrast material(s). The Plan 
denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on July 11, 2023. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for computed tomography, soft tissue neck; with contrast 
material(s) have not been met. Therefore, we decided that the Plan does not have to pay for computed 
tomography, soft tissue neck; with contrast material(s) provided on June 27, 2023.