Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lower extremity joint. 
 
You asked the Plan to pre-approve an MRI of the lower extremity joint. You say that you do not think that 
physical therapy will help your condition. You say that you would like to have the MRI done to prevent further 
damage to your knees. The Plan denied your request. The Plan says an MRI of the lower extremity joint is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of the lower extremity joint. 
Our reviewer says that the requested MRI of the lower extremity joint is not medically necessary. Our 
physician reviewer found that the enrollee's physical exam of the knees came back negative on November 15, 
2022. The x-rays did show mild bilateral degenerative changes but no effusion. Although there was mention of 
a probable enchondroma with a benign lesion of the bone and a possible joint effusion there are not details 
being offered. Therefore, there are no red flags presented to preclude a 6-week trial of physical therapy prior to 
approving an MRI of both knees. 
 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 MRI of the lower extremity joint have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an MRI of the lower extremity joint.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 15, 2022. 
 
You asked the Plan to pay for the office visit. You say that the records provided support medical necessity. 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 office visit provided 
on November 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray provided on November 02, 2022. 
 
You asked the Plan to waive the copayment for the x-ray. You say that you do not agree with the 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 $195 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $195 copayment for the x-ray. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. However, since the allowed amount is less than the standard copayment, you only owe $179.69. Therefore, we decided that the Plan does not have to waive the copayment 
for the x-ray provided on November 02, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service November 9, 
2022. 
 
You asked the Plan to pay for procedure code 87640. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 87640 is bundled into 
payment for code 87641. 
 
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 87640 
is a column II code to column I code 87641. 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 87640 billed for date of service November 9, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine 
(Tdap) (90715) and administration (90471) provided on October 20, 2022. 
 
You asked the Plan to pay for the vaccine services. You say that you understand that this vaccine is covered 
under your drug plan. You say that it the claim was denied. You also say that you were billed $129. The Plan 
denied your request. The Plan says the vaccine services are not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and 
acellular pertussis vaccine (Tdap) (90715) and administration (90471) provided on October 20, 2022.  
 Benefits for the vaccine services may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
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 necessary for the enrollee's medical 
management. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of 
care. 
 
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 treatment by multiple therapies. While the medical 
record supports a need for physical 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2377, E2300). 
 
You asked the Plan to pre-approve additional power wheelchair accessories. You say that this is medically 
necessary. The Plan denied your request. The Plan says the requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that services are covered if they are medically necessary. 
Medicare rules say that a power seat elevation feature (E2300) is not covered because it is not primarily 
medical in nature. 
 
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 additional power wheelchair 
accessories. Our reviewer says that the items are not medically necessary. Our physician reviewer found the 
enrollee has use of the upper extremity and can operate and control the power options using the switches that 
are included in the basic wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional power wheelchair accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, 
E2377, E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99072, A4649, A4556, A4557, A4253, 
S1015, S8301, and A9279 billed for date of service September 8, 2022. 
 
You asked the Plan to pay for procedure codes 99072, A4649, A4556, A4557, A4253, S1015, S8301, and 
A9279. 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. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. We also find that procedure codes A4649, A4556, A4557, and 
A4253 have a status indicator of P on the Physician Fee Schedule and no separate payment is made for these 
codes under the fee schedule as payment is bundled into the payment for the services to which these codes are 
incident to. Lastly, we find that codes S1015, S8301, and A9279 have a status indicator of I on the Physician 
Fee Schedule. This means that procedure codes S1015, S8301, and A9279 are not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of procedure codes 99072, A4649, 
A4556, A4557, A4253, S1015, S8301, and A9279 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 99072, A4649, A4556, A4557, A4253, S1015, S8301, and A9279 billed 
for date of service September 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 28, 2022, billed with 
codes 81272, 81345, and 81314. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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 
October 28, 2022, billed with codes 81272, 81345, and 81314.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service December 
22, 2022. 
 
You asked the Plan to pay for procedure code 99153. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 3 for CPT code 99153. This means there 
is only a technical component for the CPT code. The total relative value units (RVUs) for technical component 
only codes include values for practice expense and malpractice expense only. This code cannot be paid as 
billed. Based on this information, we decided that Medicare rules for coverage of procedure code 99153 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99153 billed for 
date of service December 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an air immersion mattress (E1399). 
 
You asked the Plan to pre-approve an air immersion mattress. You say that this is necessary for the enrollee. 
The Plan denied your request. The Plan says the request is not supported based on received records. 
 
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 an air immersion mattress. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not reveal an objective physical examination of the 
enrollee on medical progress notes supporting the need for the Emerg Auto Emersion therapy mattress coded 
1399 over the plan approved specialty air mattress E0194.  
 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 air immersion mattress have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an air immersion mattress (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 1, 2022, billed 
with codes 81225, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81328, 81335, 81355 and 81408. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing 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 
November 1, 2022, billed with codes 81225, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81328, 
81335, 81355 and 81408.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee requires more therapy to ensure a safe 
return home. The Plan denied your request. The Plan says that the services are not medically necessary, the 
enrollee's medical condition is currently stable. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the most recent physical therapy documentation indicates that the enrollee is alert and 
oriented and participating in therapy. The enrollee has made progress and currently requires standby assistance 
for bed mobility and minimal assistance for transfers. The enrollee is also attempting to ambulate with a hemi-
aide. The enrollee would benefit from skilled nursing facility care given their medical comorbidities. They 
would also benefit from skilled therapy services given the fact that they have had a decline in function and are 
making progress with therapy. The skilled nursing facility care is 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 99100 billed for date of service January 30, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable. 
 
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 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 procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service January 30, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Cala Trio device. 
 
You asked the Plan to pre-approve a Cala Trio device. You say that you were confused and indicated you did 
not wish to continue with this case. You say that the requested device is vital for your medical condition. You 
also say that you would like to continue this process on a regular basis. The Plan denied your request. The Plan 
says that the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 a Cala Trio device. Our reviewer says 
that the requested Cala Trio device considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation indicates you have severe essential tremor of the upper extremities. 
The documentation indicates you have failed medication therapy. Therefore, the reviewer found that the 
requested device 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 a Cala Trio device have been met. Therefore, we decided that the Plan has to 
pre-approve a Cala Trio device.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee does not meet all the requirements based on Medicare guidelines and the information received, 
services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.