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

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), electronic connection 
between wheelchair controller and two or more power seating system motors (E2311), and a harness (E2313). 
 
You asked the Plan to pre-approve an expandable controller, electronic connection between wheelchair 
controller and two or more power seating system motors, and a harness. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are covered when 
specific criteria are met. 
 
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 an expandable controller, electronic 
connection between wheelchair controller and two or more power seating system motors, and a harness. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found you do not require 
non-proportional input devices (e.g., sip and puff, head array, etc.). You do not require a separate display (i.e., 
for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or 
computer through the chair's drive control), or an attendant control. The documentation does not support that it 
is medically necessary to control the requested power options through the joystick (drive interface). Your right 
upper extremity strength and functional ability as evidenced by being independent for feeding with adaptive 
equipment should be sufficient to control any power options through their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller, electronic connection between wheelchair controller 
and two or more power seating system motors, and a harness have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable controller (E2377), electronic connection between wheelchair 
controller and two or more power seating system motors (E2311), and a harness (E2313).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration for 
the denial of an IRF admission based on medical necessity. The Plan denied your request. The Plan says the 
IRF services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
Our physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical and/or occupational therapy, there 
is no documented need for intensive rehabilitation services. 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on November 16, 2022. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid The Plan denied your request. The Plan says the primary payer's Explanation of benefits is 
required to process payment. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has to receive an 
explanation of benefits (EOB) from the enrollee's primary insurance carrier before this claim can be 
considered. As the secondary insurer, the Plan cannot be held responsible for the imaging services provided 
until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not 
have to pay for imaging services provided on November 16, 2022.
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 this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the request is not a covered benefit, The services the enrollee require 
are called custodial care. Custodial care helps you with daily needs such as dressing, bathing, getting in and out 
of bed, going to the bathroom, and eating. Custodial care is not a covered benefit under Medicare or The Plan. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily 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 skilled nursing 
facility (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 non-sterile gloves (A4927). 
 
You asked the Plan to pre-approve the non-sterile gloves. You say that the Plan covers non-sterile gloves for 
incontinence. The Plan denied your request. The Plan says this item is a hygienic item being requested for use 
by a caregiver and is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve non-sterile gloves (A4927).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on December 2, 2022, billed with codes 81317, 81292, 81298, 81295, 81300, 81319 and 81294.

You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim.

The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code.

We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on December 2, 2022, billed with codes 81317, 81292, 81298, 81295, 81300, 81319 and 81294.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) and segmental 
pneumatic appliances (E0673) provided July 26, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that please find all 
supporting documents and process your claim for payment. The Plan denied your request. The Plan says 
pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or 
following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676) and segmental pneumatic appliances (E0673) provided July 
26, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93005 and 93041 provided on December 
16, 2022. 
 
You asked the Plan to pay for procedure codes 93005 and 93041. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT codes 93005 and 93041 are packaged services due to being billed on the same claim as code 
99285, which has a status indicator of V. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 93005 and 93041 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 93005 and 93041 provided on December 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service October 10, 
2022. 
 You asked the Plan to pay for procedure code 81345. You say that this service is supported in the medical 
records. The Plan denied your request. The Plan says this service was not reported according to Medicare 
guidelines. 
 
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, we have confirmed that code 81345 
is a column II code to column I code 0089U. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 81345 billed for date of service October 10, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on December 02, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that this 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 nursing facility care 
provided on December 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint (SIJ) denervation radiofrequency 
ablation (RFA) (64635). 
 
You asked the Plan to pre-approve SIJ denervation. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says Medicare guidelines say that SIJ denervation is 
not considered reasonable and 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 SIJ denervation. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a past medical history significant for atrial fibrillation on anticoagulation, 
claudication, and peripheral artery disease who was recently seen by physical medicine and rehabilitation 
doctor due to ongoing right hip and lumbar pain. According to the literature, sacral lateral nerve branch blocks 
and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered 
experimental and investigational. Studies completed say that this procedure does not improve outcomes 
compared to standard treatment of SIJ pain. Radiofrequency ablation for denervation, whether performed using 
traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, not medically 
necessary. The review has determined that the requested SI joint RFA is not medically reasonable or 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 SIJ denervation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint (SIJ) denervation radiofrequency ablation (RFA) (64635).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on May 2, 2022, to May 5, 2022. 
 
You asked the Plan to pay for inpatient hospital services. You say that you would like full recoupment for these 
services. The Plan denied your request. The Plan says that these services have been correctly denied. 
 
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 did not support the reason for recoupment of the entire 
amount paid towards the inpatient services provided. The Plan's recoupment letter only stated that they were 
requesting a medical chart to verify the reported services. The case file shows that medical records were 
provided from the inpatient hospital services provided on May 2, 2022, through May 5, 2022. The Plan has not 
substantiated their denial reason. Therefore, we decided that the Plan has to pay for inpatient hospital services 
provided on May 2, 2022, to May 5, 2022.  
 
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 procedure code 99223 billed for date of service March 8, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity.  
 
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 billed services. Our reviewer found that 
the enrollee was admitted for hypotension and weakness. The billed code requires a comprehensive history, a 
comprehensive examination and medical decision making of high complexity. In this case, the medical records 
submitted did not support a comprehensive history. 
 
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 billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99223 billed for date of service March 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on July 13, 2022, billed with 
codes 75726-26-XU-GC x2, 75736-26-XU-GC, and 75774-26-XU-GC. 
 You asked the Plan to pay for the radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the billed codes are inclusive to payment of code 
37244. 
 
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, we have confirmed that codes 75726 x2, 75736, and 75774 are column II codes to column I code 
37244; however, 75726 x2, 75736, and 75774 were billed with a modifier.  
 
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 radiology services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found an intervention was performed and 
reported with code 37244, described as vascular embolization or occlusion for arterial or venous hemorrhage or 
lymphatic extravasation, inclusive of all radiological supervision and interpretation. Documentation does not 
support the radiological services billed as non-overlapping from the primary intervention procedure. 
 
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 radiology services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for radiological services provided on July 13, 2022, billed with codes 75726-26-
XU-GC x2, 75736-26-XU-GC, and 75774-26-XU-GC.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266). 
 
You asked the Plan to pre-approve guided tissue regeneration. You say that you are requesting reconsideration 
stating it is medically necessary for the enrollee to chew food properly. The Plan denied your request. The Plan 
says dental code D4266 is a non-covered code. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve guided 
tissue regeneration (D4266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision supply, accessory and/or service component of 
another HCPCS vision code (V2797) provided on January 5, 2023. 
 You asked the Plan to pay for vision supply, accessory and/or service component of another HCPCS vision 
code. The Plan denied your request. The Plan says the vision supply, accessory and/or service component of 
another HCPCS vision code is not a covered benefit. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the Plan vision benefit does not provide coverage 
for the requested items. Therefore, we decided that the Plan does not have to pay for vision supply, accessory 
and/or service component of another HCPCS vision code (V2797) provided on January 5, 2023.