Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable X-ray services provided on December 15, 2022. 
 
You asked the Plan to pay for portable X-ray services. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the technical component representing the 
portable X-ray procedure itself, including any associated transportation and setup costs, would be subject to 
consolidated billing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of portable X-ray services have not been met. Specifically, the case record indicates that the portable X-ray services at issue were rendered at a SNF. Portable X-ray services cannot be billed separately in a SNF 
setting. Therefore, we decided that the Plan does not have to pay for portable X-ray services provided on 
December 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit evaluation provided on January 16, 2023. 
 
You asked the Plan to pay for the home visit evaluation. 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 home visit 
evaluation provided on January 16, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE) (93306).  
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says this request 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 service. Our physician reviewer 
found at issue is the medical necessity for performance of a TTE in an asymptomatic patient without signs, 
symptoms or cardiac abnormalities on physical exam. Guidelines do not support a need for TTE in this setting. 
As a result, at this time TTE would not be considered medically appropriate and necessary in this enrollee's 
clinical management. 
 
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 a transthoracic echocardiography (TTE) (93306).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair with a patient 
weight capacity up to and including 300 pounds (K0821).  
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the DME is medically 
necessary. The Plan denied your request. The Plan says the DME is not medically necessary. 
 
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 durable medical equipment (DME). 
Our physician reviewer found the power wheelchair is not necessary as you are able to perform MRADLs 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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 2 standard power wheelchair with a patient weight 
capacity up to and including 300 pounds (K0821).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a low dose computed tomography (LDCT) lung cancer screening 
provided on January 3, 2023. 
 
You asked the Plan to pay for LDCT lung cancer screening. You say that you are appealing this denial. The 
Plan denied your request. The Plan says that the Plan did not pay for this service. 
 
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 rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees 
who meet all the criteria described in the Medicare rules section of this letter. 
 
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 denied payment for this service on the ground that the Plan paid the 
maximum allowable amount for the service; however, as the Plan made no payment of any sort this cannot be 
considered true. The record clearly shows that the enrollee met all Medicare criteria for coverage of an LDCT 
lung cancer screening. The Plan did not provide any other rationale or evidence to support a denial of payment 
in this case. Therefore, the Plan has not shown that its decision to deny payment was correct or justified. 
Therefore, we decided that the Plan has to pay for a low dose computed tomography (LDCT) lung cancer 
screening provided on January 3, 2023.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that the provided records document that the home ventilator is being requested for use in average volume assured 
pressure support (AVAPS) mode which is a modality which could be provided by a bilevel positive airway 
pressure (BiPAP) device with AVAPS and a back-up rate. The provided records do not document trial and 
failure of a BiPAP device with AVAPS and a back-up rate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued use of a home ventilator (E0466).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on 
October 11, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you should only have 
to pay 20% coinsurance. 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 $300 
copayment for outpatient surgery provided at an outpatient hospital. 
 
You have been asked to pay a $300 copayment for the diagnostic colonoscopy. This item/service falls within 
the outpatient surgery provided at an outpatient hospital 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 diagnostic colonoscopy provided on October 11, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services are not 
medically necessary.  
 
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 based on the 
medical records provided there is no documentation that home health skilled nursing services are required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair, sling/solid 
seat/back, patient weight capacity up to and including 300 pounds (K0822), detachable armrest (E0973), 22nf 
sealed lead acid battery (E2361), retractable or removable mounting hardware for joystick (E1028), and skin 
protection and positioning wheelchair seat cushion (E2607).  
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the DME is medically 
necessary. The Plan denied your request. The Plan says  the power wheelchair is requested to let the enrollee 
move around in the community and for longer distances. The Plan also says that this is not covered under 
Medicare rules.  
 
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 durable medical equipment (DME). 
Our physician reviewer found the enrollee is functionally non-ambulatory and cannot use a cane or walker for 
mobility given their risk for falling. However, the documentation does not support the fact that the enrollee can 
use a manual wheelchair for mobility. The enrollee is noted to have crepitus at their wrists, but the clinical 
documentation does not indicate a history of upper extremity osteoarthritis. The clinical documentation does 
not provide a graded assessment of the enrollee's motor strength in the upper extremities. Additionally, there is 
insufficient documentation regarding the accessibility of the enrollee's home for the requested group 2 power 
wheelchair. The enrollee indicates that they have a ramp but there is no formal accessibility evaluation 
provided. Therefore, the group 2 power wheelchair and components are 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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 2 standard power wheelchair, sling/solid seat/back, 
patient weight capacity up to and including 300 pounds (K0822), detachable armrest (E0973), 22nf sealed lead 
acid battery (E2361), retractable or removable mounting hardware for joystick (E1028), and skin protection 
and positioning wheelchair seat cushion (E2607).
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pre-approve an advanced electronic knee/foot feature for a prosthetic leg 
(L5828, L5845, L5848, L5981, L5982). 
 
You asked the Plan to pre-approve an advanced electronic knee/foot feature for a prosthetic leg. You say that 
the services are necessary. The Plan denied your request. The Plan says that based on the documentation 
provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses 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 advanced electronic knee/foot 
feature for a prosthetic leg. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found there is no doubt that original Medicare would cover the requested prosthesis for this K3-level 
enrollee. Therefore, the originally requested microprocessor knee (L5828, L5845, L5848, L5856) and foot 
(L5981, L5982) are 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 an advanced electronic knee/foot feature for a prosthetic leg have been met. 
Therefore, we decided that the Plan has to pre-approve an advanced electronic knee/foot feature for a prosthetic 
leg (L5828, L5845, L5848, L5981, L5982).  
 
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 an office visit provided on September 7, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that the services provided should be covered. The Plan 
denied your request. The Plan says the service 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 an office visit provided on September 7, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic test (81226, 81291) provided on 
January 10, 2023.  
 
You asked the Plan to pay for the GeneSight Psychotropic test. You say that   this testing was medically 
necessary.  The Plan denied your request. The Plan says there is no indication on why the provider believes this 
enrollee is at higher risk than usual. The testing is not 
considered medically necessary merely based on the enrollee's diagnosis, non-genetic factors must be 
considered.  
 
The Plan follows Medicare rules. Medicare rules say that pharmacogenomics testing is covered when the 
criteria in the rules section of this letter 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 pay for the GeneSight Psychotropic test. Our 
reviewer says that criteria for coverage are not met. Our physician reviewer found that based on review the 
records provided there is documentation of this enrollee having tried at least one medication as noted above 
which she had not responded to but was started on a new medication recently. The Medicare LCD requires the 
enrollee to be tried on at least one medication. The ordering psychiatrist must be board certified in psychiatry 
or neuropsychiatry. The ordering physician for this test is not a psychiatrist and is not boarded in psychiatry or 
neuropsychiatry. Documentation shows the severity of the enrollees depressive illness as being mild. This 
enrollee does not meet the criteria for the GeneSight Psychotropic Assay. 
 
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 GeneSight Psychotropic test have not been met. Therefore, we decided that 
the Plan does not have to pay for the GeneSight Psychotropic test (81226, 81291) provided on January 10, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 8, 
2022, to October 9, 2022.  
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were provided to the 
enrollee in good faith. You also say that you would like this claim to be reprocessed and paid based on the 
medical necessity of the enrollee's visit.  The Plan denied your request. The Plan says the information now 
received does not support that criterion were met for inpatient hospitalization.   
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the workup revealed the enrollee disoriented at times with slurred speech but 
generally alert and oriented x 3 with stable vitals. Ammonia levels were elevated and after treatment with 
lactulose, the enrollee's mentation quickly returned to baseline. Due to the low complexity and low severity of 
the enrollee's condition at the time of admission, the expected hospitalization was not expected to cross 2 
midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from October 8, 2022, to October 9, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 29, 2022, to 
May 28, 2022. 
 
You asked the Plan to pay for the home health services. You say that the NOA is still in process since 
September of 2022. 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 April 29, 2022. The NOA was not received by the Plan until March 30, 
2023. 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 the home health services 
provided from April 29, 2022, to May 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the procedure is medically necessary. 
The Plan denied your request. The Plan says that the request 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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no magnetic resonance imaging (MRI) showing only modic changes 
without facet degenerative joint disease or foraminal stenosis. The cause of back pain is not clear. 
 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.