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

 
We decided that the Plan does not have to pay for the services provided. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the 
ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, 
followed by the manifestation.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the requested services have not been met. Specifically, the record shows that the claim was billed 
with diagnosis code R18.0. This code has a code first note, which means it is a manifestation code and must be 
sequenced after an etiology code. Therefore, we decided that the Plan does not have to pay for the services 
provided.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance trip provided on April 22, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that you cannot believe this is 
being denied. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $265 
copayment for ambulance services.  
 
You have been asked to pay $248 which is less than your copayment amount of $265 for an ambulance trip. 
These services have not been denied. The appropriate copayment has been applied to the services that were 
provided to you. An ambulance trip falls 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 an ambulance trip provided on April 22, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing visits twice a week. 
 
You asked the Plan to pre-approve home health skilled nursing visits twice a week. You say that you were told 
you would get a home health nurse to come out and do the physical therapy with you and that maybe 
something was lost in the request the nurse made. The Plan denied your request. The Plan says the notes do not 
show you continue to have a medical problem that needs special care that only a nurse can do. 
 
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 skilled nursing visits twice 
a week. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
documentation doesn?t support that you require skilled nursing services to provide treatment that is medically 
necessary. You do not require skilled nursing services to effectively provide treatment, care, and/or services in 
order to improve your condition, perform a maintenance program to maintain your condition and/or prevent 
deterioration.  You have been medically stable without any recent exacerbation of chronic medical problems or 
hospitalizations. 
 
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 skilled nursing visits twice a week have not been met. Therefore, 
we decided that the Plan does not have to pre-approve home health skilled nursing visits twice a week.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 19, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the requested CPT codes are not supported in the medical record. Specifically, the records 
provided do not show that lab services were performed with blood sampling. The records show that a urine 
specimen was collected. The billed services cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on May 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synthroid tablets. 
 
You asked the Plan to pre-approve the Synthroid tablets. You say that the enrollee has been taking Synthroid 
for over a year, and has been stable on this medication. The Plan denied your request. The Plan says this drug is 
not covered for the enrollee's condition by Medicare Part B. 
 
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 Synthroid tablets.  
 
Benefits for the Synthroid tablets 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1833) provided to the enrollee on June 15, 
2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery for the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery and relevant medical records which support medical 
necessity for the supplies provided in this case. The documentation submitted did not include an itemized 
shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service. 
Therefore, the billed code cannot be verified.  The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a 
knee orthosis (L1833) provided to the enrollee on June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implantable infusion pump. 
 
You asked the Plan to pre-approve the requested service. You say that the combination of both devices will  
give the enrollee optimal relief of her pain. The Plan denied your request. The Plan says the pain pump is 
contraindicated for the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that infusion pumps are only covered under certain 
medical indications.  
 
We looked at the file and Medicare rules. The requested pump is not covered when used with other implanted 
programmable devices since crosstalk between devices may inadvertently change the prescription. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an implantable infusion pump.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on February 11, 
2020. 
 
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 99285 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 99285 is Level 5 emergency department visit for 
evaluation and management of patient with problem immediately threatening life, including comprehensive 
history and physical examination, and medical decision-making of high complexity. 
 
We asked our coder 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 these services. Our reviewer says that 
procedure code 99285 is not supported. Our coder reviewer found the medical records indicate the patient was 
presented with a headache, which she was treated for and released to go home. The records do not include 
sufficient information to validate the billed Level 5 code. 
 
We looked at this coder'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. Therefore, we decided that the Plan does not 
have to pay for the emergency room (ER) services rendered on February 11, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wireless capsule endoscopy. 
 
You asked the Plan to pre-approve the wireless capsule endoscopy. You say that you would like 
reconsideration because this service is medically necessary. The Plan denied your request. The Plan says the 
member should have a new colonoscopy per Medicare guidelines. 
 
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 wireless capsule endoscopy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documentation that a recent colonoscopy failed to identify a 
source of bleeding. 
 
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 wireless capsule endoscopy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a wireless capsule endoscopy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) 
provided to the enrollee on May 5, 2020. 
 
You asked the Plan to pay for the orthosis. 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 
enrollee's 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 knee orthosis with 
suspension sleeve (L1851, L2397) provided to the enrollee on May 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture and a complete 
mandibular denture. 
 
You asked the Plan to pre-approve the complete maxillary and mandibular dentures. You say that the dentures 
you have now are not good, and they hurt you. The Plan denied your request. The Plan says these services are 
allowed one time every 60 months. The Plan also says that you received these services less than 60 months ago. 
 
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, dentures are limited to one set every 5 
years. The record shows that you received a complete maxillary denture and a mandibular partial denture on 
December 20, 2017, and your dentures benefit has been exhausted. Therefore, we decided that the Plan does 
not have to pre-approve a complete maxillary denture and a complete mandibular denture.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the information 
submitted does not meet the Plan's medical necessity guidelines for coverage. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee has not 
tried and failed the required drug(s). Our reviewer also found that there is no indication that the Plan's required 
drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
 
 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Xarelto.  
 
Benefits for this drug 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for application of vein wound compression 
system lower leg below knee including ankle and foot (29581), removal of tissue from wounds per session, first 
20 sq cms or less (97597) and a hospital outpatient clinic visit (G0463). 
 
You asked the Plan to waive the copayments for application of vein wound compression system lower leg 
below knee including ankle and foot. You say that you do not believe you should be responsible for the cost 
share. The Plan denied your request. The Plan says the cost share is correct. 
 
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 enrollees must pay a 
$245 copay for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
You were asked to pay $191.40 out of the $245 copay for removal of tissue from wounds per session, first 20 
sq cms or less (97597), $146.50 out of the $245 copay for application of vein wound compression system lower 
leg below knee including ankle and foot (29581) and $98.50 out of the $245 copay for a hospital outpatient 
clinic visit (G0463) totaling $436.40. These services fall within the Outpatient Surgery and Other Medical 
Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This 
means that you have been asked to pay the correct amount based on the contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay upon enrolling in the Plan. Therefore, we decided that the 
Plan does not have to waive the copayments for application of vein wound compression system lower leg 
below knee including ankle and foot (29581), removal of tissue from wounds per session, first 20 sq cms or 
less (97597) and a hospital outpatient clinic visit (G0463).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nasal hemorrhage control service provided on February 
19, 2020. 
 
You asked the Plan to pay for the nasal hemorrhage control service (30903). You say that the Plan should pay 
this claim. The Plan denied your request. The Plan says the service is not supported in the medical records. 
 
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 30903 is Control nasal hemorrhage, anterior, complex 
(extensive cautery and/or packing) any method.  
 
We find that CPT code 30903 is not supported in the medical record. Specifically, the medical record says 
nasal packing was inserted into L nare and the bleeding was controlled. There is no documentation of extensive 
cautery or packing. Based on this information, we decided that Medicare rules for coverage of the nasal 
hemorrhage control service (30903) have not been met. Therefore, we decided that the Plan does not have to 
pay for the nasal hemorrhage control service provided on February 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the DEXCOM Continuous Glucose Monitor. 
 
You asked the Plan to pre-approve the DEXCOM Continuous Glucose Monitor. You say that you would like 
reconsideration because your fingers are in pain and not healing from pricking them to check your blood sugar. 
The Plan denied your request. The Plan says there is no medical documentation in your clinical history that you 
are insulin dependent and require frequent self-adjustments to your insulin dose. 
 
The Plan must follow Medicare rules. Medicare rules say that Therapeutic Continuous Glucose Monitors are 
covered when the beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a 
Medicare-covered continuous subcutaneous insulin infusion(CSII) pump; and 
the beneficiary's insulin treatment regimen requires frequent adjustment on the basis of BGM or CGM testing 
results. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the DEXCOM Continuous Glucose Monitor have not been met. The records do not indicate that 
you are insulin treated with multiple daily injections or that your treatment regimen requires frequent 
adjustment. Therefore, we decided that the Plan does not have to pre-approve the DEXCOM Continuous 
Glucose Monitor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tuberculosis skin test provided. 
 
You asked the Plan to pay for lab test. You say that the enrollee must receive this test once per year. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because this test is not a 
covered benefit for the diagnosis listed and was performed for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, lab test, was requested solely for screening purposes. Medicare does not cover 
this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for a 
tuberculosis skin test provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve these services. You say that the chair will help you shower in a safe and 
comfortable manner. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you have recurrent falls and struggle using a 
cane. 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 PWC is 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 these services. Our reviewer says that 
you do not meet the criteria for coverage. Our physician reviewer found the submitted records do not show that 
you have a mobility limitation that significantly impairs your ability to complete mobility-related activities of 
daily living (MRADLs) in the home. There is no documentation that you have a mobility limitation that cannot 
be resolved by the use of an appropriately-fitted walker or manual wheelchair. The PWC is 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. Therefore, we decided that the Plan does not 
have to pre-approve a Group 2 power wheelchair (PWC).
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 these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a power seat elevation feature is not covered. 
 
We looked at the file and Medicare rules. The item at issue is a power seat elevation feature. This item is not 
covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation 
system.