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

 
We decided that the Plan does not have to pre-approve an expandable controller (E2310, E2311, E2313, 
E2377) and a footplate cover (K0108) for an approved power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that these items are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that items that are not primarily medical in nature are non-
covered. The rules also state that expandable controllers are covered only when 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 wheelchair accessories. Our 
reviewer says that the requested items are not medically necessary. Our physician reviewer found the footplate 
cover is non-medical in nature and is considered a deluxe item. It is not eligible for coverage. The records 
provided show that the enrollee can operate the power functions through their own switches. The expandable 
controller is 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 the wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable controller (E2310, E2311, E2313, E2377) and a footplate 
cover (K0108) for an approved power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
February 08, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you would like to appeal 
this charge. 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 $15 
copayment for specialist physician/practitioner services. 
 
You have been asked to pay a $15 copayment for the specialist office visit. This item/service falls within the 
specialist physician/practitioner services 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 specialist office visit provided on February 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87186 and A9270 billed for date of service 
December 13, 2022, to December 15, 2022. 
 
You asked the Plan to pay for procedure codes 87186 and A9270. The Plan denied your request. The Plan says 
the billed services are not payable. 
 
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 87186 
is a column II code to column I code 87181. 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. 
 
We also find that procedure code A9270 has a status indicator of N on the Physician Fee Schedule. This means 
that procedure code A9270 is not covered. Based on this information, we decided that Medicare rules for 
coverage of procedure code A9270 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes 87186 and A9270 billed for date of service December 13, 2022, to December 15, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemcitabine, Opdivo, Topotecan, Etoposide, Thiotepa, 
and Methotrexate. 
 
You asked the Plan to pre-approve Gemcitabine, Opdivo, Topotecan, Etoposide, Thiotepa, and Methotrexate. 
You say that the records provided support the need for the requested drugs.  The Plan denied your request. The 
Plan says the requested regimen is not reasonable and necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Gemcitabine, Opdivo, Topotecan, 
Etoposide, Thiotepa, and Methotrexate. Our reviewer says that the criteria for coverage have not been met.  Our physician reviewer found the requested use of Gemcitabine, Opdivo, Topotecan, Etoposide, Thiotepa, and 
Methotrexate is not FDA-approved for the enrollee's diagnosis. The use of this drug regimen is not supported 
by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical 
journal.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gemcitabine, Opdivo, Topotecan, Etoposide, Thiotepa, and Methotrexate have 
not been met. Therefore, we decided that the Plan does not have to pre-approve Gemcitabine, Opdivo, 
Topotecan, Etoposide, Thiotepa, and Methotrexate.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
April 19, 2022. 
 
You asked the Plan to pay for procedure codes 99601 and 99602. You say that these are Medicare covered 
services. The Plan denied your request. The Plan says the billed codes are 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 codes 99601 and 99602 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes 99601 and 99602 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date 
of service April 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on December 21, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the home visit. You say that the provider was not responsible for obtaining 
authorization. The Plan denied your request. The Plan says enrollees must receive their care from a network 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the item/service at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for this item/service. Therefore, 
we decided that the Plan does not have to pay for the home visit provided on December 21, 2022, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and imaging provided on November 23, 2022, 
billed with codes 99205 and 92201. You asked the Plan to pay for the EM services and imaging as billed. You say that this is billed correctly and 
should be paid.  The Plan denied your request. The Plan says the codes are not supported.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 92201 is a column II code to column I code 67145; however, 92201 
was billed with a modifier.  
 
In addition, the CPT code manual definition of 99205 is Office or other outpatient visit for the evaluation and 
management of a new patient, which requires a medically appropriate history and/or examination and high 
level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on 
the date of the encounter. 
 
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 EM services and imaging as billed. Our reviewer says 
that code 99215 is not supported, and the modifier used for 92201 is not clinically appropriate.  Our reviewer 
found both of the services billed would be considered inclusive to the primary procedure described by code 
67145. 
 
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 EM services and imaging as billed have not been met. Therefore, we 
decided that the Plan does not have to pay for the office visit and imaging provided on November 23, 2022, 
billed with codes 99205 and 92201.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room (ER) services rendered on September 29, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the claim must be resubmitted under Part B. 
 
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. The Plan states that the claim must be resubmitted under Part B; however, the 
claim has been correctly submitted to Part B. The Plan has not provided any documentation or binding 
Medicare rules to support that the claim is not payable as billed. Therefore, we decided that the Plan has to pay 
for the emergency room (ER) services rendered on September 29, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 12, 2022, to July 
21, 2022. 
 You asked the Plan to pay for home health services. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final 
claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is July 12, 2022. The NOA was not received by the Plan until September 28, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from July 12, 2022, to July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99215 billed for date of service March 16, 2022. 
 
You asked the Plan to pay for code 99215. You say that the medical records support payment of this code. The 
Plan denied your request. The Plan says the medical records do not support the billing of code 99215. The 
records don't support high level of medical decision making or total time required. 
 
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 99215 is Office or other outpatient visit for the evaluation 
and management of an established patient, which requires at least two of these three key components: a 
comprehensive history; a comprehensive examination; medical decision making of high complexity. 
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family. 
 
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 code 99215. Our reviewer says that code 99215 is not 
supported by the medical records. Our reviewer found  the enrollee was a then, 54 year old male with a history 
of chronic pain syndrome, cervical radiculopathy, status post intrathecal pain pump. chronic myelopathy, and 
post laminectomy syndrome who was evaluated on March 16, 2022, for an intrathecal pain pump adjustment. 
There was no medical decision making of high complexity, so code 99215 cannot be supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99215 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99215 billed for date of service March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on November 2, 2022, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for nursing facility care. You say that this is supported in the records. The Plan 
denied your request. The Plan says this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for nursing facility care provided on November 2, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 billed for date of service July 22, 
2022. 
 You asked the Plan to pay for procedure code 99213. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says payment for code 99213 is bundled into payment for 
code 20610. 
 
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 99213 is a column II code to column I code 20610; however, 99213 
was 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 procedure code 99213. Our reviewer says that procedure 
code 99213 does not meet criteria for payment. Our reviewer found that the medical records provided do not 
include sufficient documentation to validate appending modifier 25 to CPT code 99213, as the documentation 
does not verify this was a separately identifiable evaluation and management service by the same physician or 
other qualified health care professional on the same day of a procedure or other service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99213 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99213 billed for date of service July 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA testing (81479) provided January 5, 2023. 
 
You asked the Plan to pay for PrismRA testing. You say that you are requesting reconsideration of the denial 
over coverage and payment for PrismRA testing. The Plan denied your request. The Plan says this test is not FDA approved and based on the diagnostic program, MolDX Technical Assessment, the requested PrismRA 
test is not an approved test. 
 
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. Online search of the FDA list of cleared or approved companion 
diagnostic testing does not mention this PrismRA. Search of the DEX Diagnostic Exchange registry for the 
diagnostic program MolDX Technical Assessment, states that this PrismRA test is not covered. Based on this 
information, we decided that Medicare rules for coverage of PrismRA testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the PrismRA testing (81479) provided January 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - comprehensive series of radiographic images 
(D0210), panoramic radiographic image (D0330), and cone beam (D0367) provided on February 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for imaging has already been exhausted and cone beams are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 8, 2023. Therefore, we decided that the Plan does not have to pay for intraoral - comprehensive series of radiographic 
images (D0210), panoramic radiographic image (D0330), and cone beam (D0367) provided on February 8, 
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 the services are medically necessary as the enrollee 
was independent prior to surgery. The Plan denied your request. The Plan says the services the enrollee needs 
can be provided safely in another setting such as a skilled nursing facility,  
 
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 enrollee does not require the intensity of services provided at an IRF. The 
enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician 
evaluation. The enrollees care needs can be met at a lower 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: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 01440 and 36620. We 
decided that the Plan does not have to pay for the services described by procedure code(s) 99100.  
 
You asked the Plan to pay for the medical services provided on December 5, 2022, billed with codes 01440, 
36620, and 99100.. You say that this should be paid as billed.  The Plan says that an appeal decision was not 
made for two of the codes, as the claim was to be reopened. Code 99100 is not separately payable.  
 
We decided that the Plan has to pay for the services described by procedure code(s) 01440 and 36620.  
 
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 make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 01440 and 36620.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99100. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare rules say that providers must report services 
correctly. Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of code 99100 have not been met. Therefore, we decided that the Plan does not have to pay for the 
services described by procedure code(s) 99100. 
 
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.