Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit rendered on July 19, 2019. 
 
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 procedure code 99350 is 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, the CPT Code Manual definition of code 99350 is Level 4 home visit for the evaluation and 
management of established patient with problem of moderate to high severity, including comprehensive 
interval history and medical decision making of moderate to high complexity - typical time with patient and/or 
family 60 minutes. 
 
We find that CPT code 99350 is not supported in the medical record. Specifically, the records show that the 
services were rendered by a social worker and this provider type is not appropriate for this code. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the home visit rendered on July 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of an implant body: endosteal 
implant (D6010). 
 
You asked the Plan to pre-approve the endosteal implant. You say that your oral surgeon is recommending a 
dental implant because your tooth cannot be saved. The Plan denied your request. The Plan says this service is 
not covered under your benefit plan. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
surgical placement of an implant body: endosteal implant (D6010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are not more than three daily injections of insulin in this case. 
 
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 monitor. Our reviewer says that the 
requested monitor is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not support the enrollee is checking blood glucose levels four or more times a 
day. Without the support of the documentation, medical necessity cannot be determined. 
 
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by an OON provider. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to continue dental care with 
your long time dentist who is OON. The Plan denied your request. The Plan says the provider you are 
requesting to receive services from is OON. The Plan also says that there are contracted Plan providers 
available for you to receive your routine dental care from. 
 
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 items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve dental 
services to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a foot rest and elevating leg rest. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The items at issue are a foot rest and elevating leg rest described by codes K0044 and K0047. These codes are 
column II codes when billed with approved column I code for K0005 for the manual wheelchair and cannot be 
approved. Therefore, we decided that the Plan does not have to pre-approve a foot rest and elevating leg rest.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power operated vehicle. 
 
You asked the Plan to pre-approve a Group 2 very heavy duty power operated vehicle (K0808). You say that 
you need a power mobility device to get to the bathroom. The Plan denied your request. The Plan says 
Medicare does not cover this type of power mobility device. 
 
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.  
 
Neither Medicare nor the Plan cover this type of PMD. Therefore, we decided that the Plan does not have to 
pre-approve a Group 2 power operated vehicle.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve these services. You say that you need transportation to your doctor 
appointments. The Plan denied your request. The Plan says you have exhausted the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve more for a surgical placement of implant body: 
endosteal implant, or pre-approve a custom fabricated abutment, and abutment supported porcelain/ceramic 
crown. 
 
You asked the Plan to pre-approve more for the endosteal implant, and pre-approve a custom fabricated 
abutment, and abutment supported porcelain/ceramic crown. You say that this treatment is urgent in order to 
avoid problems in your oral health and overall health. The Plan denied your request. The Plan says the 
quarterly allowance has been exhausted. 
 
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 Plan offers a quarterly allowance of 
$125. The record shows that you were approved $150 for an extraction, and $31 for the endosteal implant, and 
therefore you met the quarterly benefit on June 30, 2020 when these services were approved, and your second 
quarterly benefit has been exhausted. At the time of the initial request, there was no sufficient funds available 
in the benefit to cover all of the requested services. However, you can re-appeal now that you may have funds 
left from the third quarter, and there will also be an additional $125 allowance available beginning October 1, 
2020. Therefore, we decided that the Plan does not have to pre-approve more for a surgical placement of 
implant body: endosteal implant, or pre-approve a custom fabricated abutment, and abutment supported 
porcelain/ceramic crown.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide an advanced pneumatic compression device (E0652). 
 
You asked the Plan to provide an advanced pneumatic compression device. You say that the enrollee needs an 
advanced pneumatic compression device and garments. The Plan denied your request. The Plan says there was 
not a four week trial of a basic pneumatic compression device and garments. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to provide an advanced pneumatic compression 
device (E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left knee genicular nerve radiofrequency ablation (RFA) 
for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says genicular radiofrequency ablation and genicular nerve blocks are considered 
experimental, investigational and unproven for the treatment of chronic knee pain, including degenerative joint 
disease or osteoarthritis of the knee. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is considered an experimental/investigational procedure that is the subject of on-going clinical trials. 
Therefore, the request is deemed 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve left knee genicular nerve radiofrequency ablation (RFA) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system. 
 
You asked the Plan to pre-approve power seat elevation system. You say that you are appealing based on 
medical necessity. The Plan denied your request. The Plan says the denial of authorization for this item is 
correct, because a power seat elevation feature is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is not covered by 
Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of power seat elevation system have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power seat elevation system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery backup. 
 
You asked the Plan to pre-approve the backup. You say that the power is going out unexpectedly. The Plan 
denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
A backup battery is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve a 
battery backup.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Pride Mobility Go-Go Folding scooter. 
 
You asked the Plan to pre-approve a Pride Mobility Go-Go Folding scooter. You say that the requested Pride 
Mobility Go-Go Folding Scooter is medically necessary. The Plan denied your request. The Plan says the 
requested Pride Mobility Go-Go Folding Scooter 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 a Pride Mobility Go-Go Folding 
scooter. Our reviewer says that the requested Pride Mobility Go-Go Folding Scooter is not medically 
necessary. Our physician reviewer found the requested power mobility scooter (Pride Mobility Go-Go Folding 
scooter) is not medically necessary.  The documentation reveals that the enrollee has a personal mobility deficit 
that impairs participation in mobility related activities of daily living in the home. The documentation is not 
clear why the enrollee's mobility deficit is unable to be helped by a walker or manual wheelchair. The enrollee 
was stated to have generalized weakness of upper body and cannot mobilize in a wheelchair. She was noted 
unable to do activities of daily living even with a cane, walker, or crutch. This is conflicting with the 
documentation that indicates neurological system is normal and there is no evidence of a detailed upper 
extremity evaluation with motor strength of the individual myotomes or range of motion exam. The 
documentation reveals no objective assessment of measurements in her home to evaluate that the enrollee can 
safely maneuver the PMD within the home. The requested brand of power mobility scooter is not medically 
necessary as the documentation is not clear that this particular brand is reasonable and necessary for the 
diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. 
 
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 Pride Mobility Go-Go Folding scooter have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Pride Mobility Go-Go Folding scooter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient surgery to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve an outpatient surgery. You say that you cannot find anyone in-network who 
can provide this surgery. The Plan denied your request. The Plan says there are in-network providers available 
for these services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an outpatient surgery to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group two power wheelchair for the enrollee. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says no clinical notes were received from the provider. 
 
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 patient?s 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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the enrollee is 
unable to use a walker, cane, or manual wheelchair due to the personal mobility deficit due to weakness. The 
enrollee cannot safely operate the PMD as the documentation indicates that his weight exceeds the 300 pound 
limit for the requested K0821 power wheelchair, group 2 standard, portable, captain's chair, patient weight 
capacity up to and including 300 pounds. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group two power wheelchair for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.

You asked the Plan to pre-approve routine transportation. You say that you have had an additional accident and are sure you will need transportation to additional appointments. The Plan denied your request. The Plan says the denial of authorization for additional routine transportation trips is correct, because routine transportation beyond 24 one-way trips per calendar year is not covered by the Plan.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve waterjet tissue ablation therapy (0421T).

You asked the Plan to pre-approve waterjet tissue ablation therapy. You say that you had the surgery in September of 2017 and it did not go well. The urologist failed to remove enough tissue and the recovery was over four months. The Plan denied your request. The Plan says waterjet tissue ablation for the treatment of enlarged prostate is not covered by Medicare because it is considered experimental/investigative or unproven.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of waterjet tissue ablation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve waterjet tissue ablation therapy (0421T).
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 based on the documentation provided, the health plan?s denial should be upheld.  The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthetic leg and any associated parts to be provided by 
an out-of-network provider. 
 
You asked the Plan to pre-approve the items. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are available by a provider in the enrollee's network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
prosthetic leg and any associated parts to be provided by an out-of-network provider.