Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hand held shower. 
 
You asked the Plan to pre-approve these services. You say that you do not have someone to help you in the 
shower. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a hand held shower.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health aide services (S9122) received. 
 
You asked the Plan to pay for a home health aide. You say that the Plan must reconsider the denial of payment. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the services at issue were provided by a 
provider that appears to not be certified for Medicare. The provider at issue did not come up on the 
Medicare.gov search for Home Health providers serving the enrollee's area. There was no documentation 
supplied by the provider to verify that they are certified by Medicare. Therefore, we decided that the Plan does 
not have to pay for home health aide services (S9122) received.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve low air loss mattress (E0277). 
 
You asked the Plan to pre-approve the medical bed supplies. You say that the services are necessary. The Plan 
denied your request. The Plan says the enrollee does not meet coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that to qualify for a group 2 support surface, the 
beneficiary must meet specific criteria.  
 
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 medical bed supplies. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found determined that the information 
provided does not show that the member has qualifying pressure ulcers. In addition, it appears the member's 
need could be met with a group 1 support surface due to immobility and incontinence. The beneficiary does not 
have multiple stage II pressure ulcers located on the trunk or pelvis or has large or multiple stage III or IV 
pressure ulcer(s) on the trunk or pelvis. The beneficiary has not had a myocutaneous flap or skin graft for a 
pressure ulcer on the trunk or pelvis within the past 60 days (refer to the ICD-10 code list section in the LCD-
related Policy Article for applicable diagnoses), and has not been on a group 2 or 3 support surface 
immediately prior to discharge from a hospital or nursing facility within the past 30 days. 
 
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 medical bed supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve low air loss mattress (E0277).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CancerTYPE ID testing (oncology mRNA gene 
expression profiling). 
 
You asked the Plan to pre-approve CancerTYPE ID testing. You say that you are appealing with records. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because this 
testing 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 CancerTYPE ID testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has pancreatic cancer which is an aggressive neoplasm with poor 
survival. Molecular testing would not be medically necessary in this particular situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CancerTYPE ID testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve CancerTYPE ID testing (oncology mRNA gene expression profiling).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve CT scan, abdomen and pelvis; with contrast material(s) (CPT 
Code 74177). 
 
You asked the Plan to pre-approve the CT scan. You say that the member has a history of chronic diarrhea for a 
year with unremarkable lab and stool studies results. The Plan denied your request. The Plan says that the 
Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT scan. Our physician reviewer 
found the CT scan is indicated in longstanding refractory diarrhea. Certainly not a test to be done early, but 
differential of colitis or pancreatic insufficiency can elucidated from CT scan. At this point the test 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 the CT scan have been met. Therefore, we decided that the Plan has to pre-
approve CT scan, abdomen and pelvis; with contrast material(s) (CPT Code 74177).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair. 
 
You asked the Plan to pre-approve the group 3 power wheelchair. You say that you would like reconsideration 
because the requested wheelchair is medically necessary for your independence and comfort. The Plan denied 
your request. The Plan says you do not have a qualifying condition for the requested wheelchair. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or 
congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 
power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve frames (V2020) and lenses (V2200). 
 
You asked the Plan to pre-approve frames and lenses. You say that the service should be covered because the 
first pair was stolen. The Plan denied your request. The Plan says you have exhausted your maximum benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one comprehensive vision examination and one complete frame and pair of lenses 
per twenty-four month period. 
 
We looked at the file and the Plan's rules. Records show you have exhausted your benefit for one pair of 
eyeglasses per twenty-four month period. Based on this information, we decided that the Plan's rules for 
coverage of frames and lenses have not been met. Therefore, we decided that the Plan does not have to pre-
approve frames (V2020) and lenses (V2200).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of the torus mandibularis (D7473), an 
initial 15 minutes of conscious sedation (D9243 x 2), and an additional 15 minutes of conscious sedation 
(D9239). 
 
You asked the Plan to pre-approve the dental services. You say that a plan representative advised that the 
service would be covered. You say that you do not believe that the removal of the Tori bone is a dental service. 
You also say that the procedure was listed differently on the treatment plan. The Plan denied your request. The 
Plan says removal of the torus mandibularis is not listed as a covered service. The Plan says that conscious 
sedation is not listed as a covered service either. 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 the 
removal of the torus mandibularis (D7473), an initial 15 minutes of conscious sedation (D9243 x 2), and an 
additional 15 minutes of conscious sedation (D9239).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on November 4, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT codes. In this case, the claim submitted does not have 
the codes and modifier required for this service as stated above. Medicare billing criteria are not met. 
Therefore, we decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing 
provided to the enrollee on November 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable oxygen concentrator (POC). 
 
You asked the Plan to pay for the DME. You say that you need the POC because you need the portable oxygen 
when you travel to doctor's offices which is an hour long each way and it's too many tanks that you have to 
take. The Plan denied your request. The Plan says they were not provided with a physician's order or 
supporting clinical information to indicate that the portable oxygen tanks provided to you are not meeting your 
needs for supplemental oxygen. 
 
 
 
The Plan must follow Medicare rules. Based on this information, we decided that Medicare rules for coverage 
of the DME have not been met. In order to determine if your oxygen needs require, a portable oxygen 
concentrator your physician must provide a physician's order and supporting documentation that shows you are 
unable to use the portable oxygen tanks provided. Therefore, we decided that the Plan does not have to pay for 
portable oxygen concentrator (POC).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on July 17, 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 71045 is not separately payable. 
 
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 provider submitted a claim for procedure codes 71045 and 32555. Code 71045 is a column II code with a 
modifier indicator of 1 when billed with column I code 32555. Code 71045 was not billed with an appropriate 
modifier to allow for separate payment. 
 Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered on July 17, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the item is necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that a portable oxygen system is covered when specific 
criteria is 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 a portable oxygen concentrator. Our 
reviewer says that the item is medically necessary. Our physician reviewer found you are mobile with a room 
air oxygen saturation of 86% and a medical note of December 15, 2020 documents that portable oxygen tanks 
are too heavy for you to carry with your walker. In addition there is documentation that the tanks do not last 
long enough to supply oxygen through your chemotherapy sessions for your liver cancer. 
 
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 portable oxygen concentrator have been met. Therefore, we decided that the 
Plan has to pre-approve a portable oxygen concentrator (E1392).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve portable oxygen concentrator. 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that the oxygen tanks run out and 
are difficult to carry around. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the portable oxygen concentrator have not been met. Per Medicare 
guidelines, specifically Policy Article A52514, oxygen and oxygen equipment will be approved when it is 
determined to be reasonable and necessary. Coverage is limited to payment for one stationary oxygen system 
and one portable oxygen system per month. Requesting a portable oxygen concentrator, in addition to the home 
and portable oxygen equipment you are already using, is not considered reasonable and necessary. Therefore, 
we decided that the Plan does not have to pre-approve portable oxygen concentrator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 26, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this is a duplicate of a previously processed 
and paid claim. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, the record indicates that this is a duplicate 
claim to another which was previously processed and paid by the Plan. Therefore, we decided that the Plan 
does not have to pay for laboratory services provided on February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical preparation (15004 and 15005) provided on 
February 20, 2020, through March 12, 2020. 
 
You asked the Plan to pay for the surgical preparation. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support the services billed. 
 
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 15004 is surgical preparation or creation of recipient site 
by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar 
contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 
sq cm or 1% of body area of infants and children. 
 
The CPT Code Manual definition of code 15005 is surgical preparation or creation of recipient site by excision 
of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, 
face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; each additional 100 
sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to 
code for primary procedure). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the surgical preparation. Our reviewer says that CPT codes 
15004 and 15005 do not meet criteria for billing and reimbursement consideration. Our reviewer found the 
medical records provided does not include documentation to validate that CPT 15004 and CPT 15005 were  
separate procedures on February 20, 2020 or March 12, 2020, therefore this service cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgical preparation have not been met. Therefore, we decided that the Plan 
does not have to pay for surgical preparation (15004 and 15005) provided on February 20, 2020, through 
March 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for the office visit and injections provided on April 
27, 2020 and the CT scan provided on May 12, 2020 and June 4, 2020. 
 
You asked the Plan to waive the cost for the office visit, injections and CT scan. You say that you were 
informed the office was billing the services incorrectly. You say that you should not be responsible for the bill. 
The Plan denied your request. The Plan says the cost share applied 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 $5 
copayment for provider and professional services at an in-network PCP's office, 20% coinsurance for Medicare 
Part B covered drugs at an in-network PCP's office and a $150 copayment for advanced imaging services at an 
in-network PCP's office, specialist's office or freestanding radiological facility.  
 
 
You have been asked to pay a total of $306.70 for the office visit, injections and CT scan.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
April 27, 2020 Office Visit $109.18 $5 $5 
April 27, 2020 Injections $8.51 20% $1.70 
May 12, 2020 CT Scan $192.75 $150 $150 
June 4, 2020 CT Scan $197.23 $150 $150 
TOTAL:    $306.70 
 
The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit 
category. The injections fall within the "Medicare Part B prescription drugs" benefit category. The CT scans 
fall 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. Therefore, we decided that 
the Plan does not have to waive the cost for the office visit and injections provided on April 27, 2020 and the 
CT scan provided on May 12, 2020 and June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided from January 22, 2020, to 
January 31, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you tried to obtained retro authorization but the 
Plan does not accept that. The Plan denied your request. The Plan says prior authorization was not obtained. 
The Plan says that the referring provider is also out-of-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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physician services provided from January 22, 
2020, to January 31, 2020, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve segmental pneumatic appliance for use with pneumatic 
compressor, full leg (CPT Code E0667) and pneumatic compressor, segmental home model without calibrated 
gradient pressure (E0651). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. There is no clinical proof of a 
diagnosis of Lymphedema. Therefore, we decided that the Plan does not have to pre-approve segmental 
 
 
pneumatic appliance for use with pneumatic compressor, full leg (CPT Code E0667) and pneumatic 
compressor, segmental home model without calibrated gradient pressure (E0651).