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

 
We decided that the Plan does not have to pay for the nervous system procedure provided on July 2, 2020. 
 
You asked the Plan to pay for the services provided. You say that medical records support medical necessity. 
The Plan denied your request. The Plan says the billed procedure code is not on the list for covered surgical 
procedures. 
 
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 64999 is unlisted procedure, nervous system. We looked 
at the file and the rules. We find that CPT code 64999 is not among the surgical procedures that are covered 
ambulatory surgical center services. 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 the 
nervous system procedure provided on July 2, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from April 
8, 2020 to April 30, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, NRS 
supplies are indicated in the HIPPS code and are not submitted on the claim. If non-routine supplies were not 
provided, the HHA must indicate that on the claim by changing the fifth position of the HIPPS code to the 
appropriate numeric value in the range 1 through 6. The provider did not bill with an appropriate home health 
data. Therefore, we decided that the Plan does not have to pay for the home health services provided to the 
enrollee from April 8, 2020 to April 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe compression stockings identified with code A4467 that were issued on July 14, 2020.You asked the Plan to pay forthe compression stockings. You say that you shouldn't have to pay for this because it was part of a procedure.The Plan denied your request. The Plan says this is not a covered benefit because it is a non-reusable supply and not a rental-type item.The Plan must follow Medicare rules. The rules say that compression stockings described by code A4467 are noncovered because they do not meet the statutory definition of a brace because they are not rigid or semi-rigid devices.Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pay forthe compression stockings identified with code A4467 that were issuedon July 14, 2020
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on July 6, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you did not call the 
ambulance. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
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 $250 
copayment for ambulance services.  
 
You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the 
ambulance 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 ambulance services 
provided on July 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management services coded 
99239 provided on December 4, 2019. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 
supported by the documentation. 
 
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 99239 is hospital discharge day management. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation submitted 
does not include a hospital discharge day management note with a recorded duration of time of 
31 minutes or more for the billed date of service. Based on this information, we decided that Medicare rules for 
coverage of the hospital discharge day management services have not been met. Therefore, we decided that the 
Plan does not have to pay for the hospital discharge day management services coded 99239 provided on 
December 4, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health aide (S9122) provided on August 2, 2019 
through August 12, 2019. 
 
You asked the Plan to pay for a home health aide. You say that the services were medically necessary The Plan 
denied your request. The Plan says the services were obtained from a provider who is not under contract with 
the health plan and is not certified for Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, the record indicates that the provider at issue was 
not enrolled with Medicare for the date of service at issue. There was no documentation to verify the provider's 
enrollment in Medicare for the date of service at issue.  
 
 
 
 
 
 
 
 
Therefore, we decided that the Plan does not have to pay for a home health aide (S9122) provided on August 2, 
2019 through August 12, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the Collagen Crosslinking Corneal procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says that this is considered investigational, and is therefore is not medically reasonable 
and 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 the procedure. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the collagen crosslinking corneal procedure has been shown to improve visual acuity and topographic 
parameters in patients with keratoconus. The procedure is medically reasonable and necessary for the enrollee 
in this case. 
 
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 procedure have been met. Therefore, we decided that the Plan has to pre-
approve the Collagen Crosslinking Corneal procedure for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 power wheelchair (PWC) with extra battery. 
 
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 medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 1 PWC is covered when specific criteria 
are met. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the 
home. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a personal mobility 
deficit that impairs participating in mobility-related activities of daily living (MRADLs) in the home; however, 
the documentation does not reveal that the mobility deficit cannot be helped by a manual wheelchair. The face-
to-face evaluation on November 13, 2020 states this will be used in and out of the home for daily activities. 
The services are therefore not reasonable or 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 these services have not been met. Furthermore, the file shows that the PWC is 
being requested for use outside of the home and Medicare does not cover this item for this purpose. Therefore, 
we decided that the Plan does not have to pre-approve a Group 1 power wheelchair (PWC) with extra battery.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve abdominoplasty and panniculectomy. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary, as there is excess 
skin. The Plan denied your request. The Plan says that there must be documentation of a significant functional 
deficit. 
 
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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found, it is documented that you have "severe excess fat on the upper and lower abdomen" "severe 
upper laxity and diastasis" and "very wide diastasis of the RA muscle as well." While there is no 
documentation of skin abnormality, the documentation supports that the procedure is medically reasonable and 
necessary in this case to correct or relieve defects of the enrollee's abdominal wall. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve abdominoplasty and panniculectomy.  
 
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 pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with 
suspension sleeve (L1833, L2397) provided to the enrollee on June 3, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollees condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
 
 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis 
(L0650) and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on June 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve the Volara system. You say that the device is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 Volara system. Our reviewer says 
that the requested device is not medically necessary. Our physician reviewer found the patient has 
bronchiectasis and other imaging findings in the lung, in the setting of asthma. It is not clear from the records 
whether diagnoses such as allergic bronchopulmonary aspergillosis or pulmonary infection with atypical 
mycobacteria, either of which can cause bronchiectasis, have been considered and excluded. The 
manufacturer's website references only one study supporting the efficacy of this device. This study looked at 
postoperative patients in terms of complications and hospital stay. It did not study patients with bronchiectasis. 
 
 
 
 
 
 
 
 
 
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 Volara system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Volara high frequency chest wall oscillation device (HFCWOD).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventive service (D1999) provided on 
August 19, 2020. 
 
You asked the Plan to pay for the dental service. You say that  The Plan denied your request. The Plan says the 
unspecified preventive service is not a covered service. 
 
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 pay for the 
unspecified preventive service (D1999) provided on August 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on January 22, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-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 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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to you by an out-of-network provider on 
January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on April 16, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the service were not 
approved in advance. 
 
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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on April 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the non-preferred brand of test strips. 
 
You asked the Plan to pre-approve the non-preferred brand of test strips. You say that you ordered a non-
preferred brand of test strips.  The Plan denied your request. The Plan says there is no medical reason 
documented that the enrollee is medically unable to use the Plan preferred test strips. 
 
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. There is no physician documentation that the non-preferred brand is 
necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for 
coverage of the non-preferred brand of test strips have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the non-preferred brand of test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nurtec ODT 75mg tablet for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nurtec ODT 75mg tablet 
for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 bone replacement grafts (D7953), 2 abutment 
supported crowns (D6059), 2 custom abutments (D6057), 2 implants (D6010), 2 bone grafts at the time of 
implant placement (D6104), 4 unspecified preventive services (D1999), 4 gingival irrigation (D4291), and the 
scaling in the presence of generalized moderate or severe gingival inflammation (D4346). 
 
You asked the Plan to pre-approve the dental services. You say that you did not request implants. You also say 
that you do not know why the codes were denied. The Plan denied your request. The Plan says the requested 
dental services are not listed as covered. The Plan also says that any services not listed 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 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 2 
bone replacement grafts (D7953), 2 abutment supported crowns (D6059), 2 custom abutments (D6057), 2 
implants (D6010), 2 bone grafts at the time of implant placement (D6104), 4 unspecified preventive services 
(D1999), 4 gingival irrigation (D4291), and the scaling in the presence of generalized moderate or severe 
gingival inflammation (D4346).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric patient lift (E0635). 
 
You asked the Plan to pre-approve this item. You say that an electric patient lift is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that an electric patient lift is not indicated but a hydraulic 
sit to stand lift is medically appropriate. 
 
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 this item. Our reviewer says that the 
requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found 
that the requested electric patient lift is not medically necessary as Medicare does not pay for any items or 
services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve 
the functioning of a malformed body member. The documentation does not reveal that the electric patient lift is 
more beneficial than a sit to stand hydraulic lift. There is no evidence that the electric patient lift is more 
effective or safer than the sit to stand hydraulic lift for this patient at this time. Therefore, this request cannot be 
considered 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 this item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an electric patient lift (E0635).