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

 
We decided that the Plan has to pay for the hip orthosis (L1686) and addition to lower extremity, pelvic 
control, hip joint, adjustable flexion, extension, abduction control (L2624) provided on September 21, 2022. 
 
You asked the Plan to pay for the hip orthotics. You say that the orthotics are necessary for the enrollee. The 
Plan denied your request. The Plan says that the provided documentation does not support the billed codes. 
 
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 contains a valid physician order, proof of delivery, and relevant medical records which support 
medical necessity for the supplies provided in this case. Therefore, we decided that the Plan has to pay for the 
hip orthosis (L1686) and addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, 
abduction control (L2624) provided on September 21, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0241U) provided on December 21, 
2022. 
 
You asked the Plan to pay for procedure code 0241U. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of procedure code 0241U 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
(0241U) provided on December 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on May 21, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
emergency medical services (EMS) team told you that you did not have to go to the hospital after they revived 
you. You also that that it isn't fair you are being charged when EMS told you that you did not need to go to the 
hospital. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 21, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on May 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator (E0466). 
 
You asked the Plan to pre-approve a home mechanical ventilator. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the request for a home mechanical ventilator set in TTV-VAPS 
mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that claims for ventilators used to provide continuous 
positive airway pressure (CPAP) or bi-level CPAP therapy will be denied as not reasonable and necessary.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home mechanical ventilator. Our 
reviewer says that the member does not need this item. Our physician reviewer found provided records 
document that the home ventilator is being requested for use in targeted tidal volume - volume assured pressure 
support (TTV-VAPS) mode with auto-titration (AE) which could be provided by a BiPAP device with average 
volume assured pressure support (AVAPS) and a back-up rate. Provided records do not document trial and 
failure of a BiPAP device with AVAPS and a back-up rate. 
 
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 home mechanical ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home mechanical ventilator (E0466).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on August 21, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you had an 
insulin overdose. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 21, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on August 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274) provided on 
October 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that the claim was for an irritated tooth and to 
determine the source of the irritation. You also say that the bitewing x-ray was to evaluate the tooth and root 
health. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 10, 2022. Therefore, we decided that the Plan does not have to pay for bitewings - four radiographic images (D0274) 
provided on October 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat elevation and standing features. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee needs to access multiple 
heights. The Plan denied your request. The Plan says the services are statutorily non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 We looked at the file and the rules. The item at issue in this appeal does not serve a purpose that is primarily 
medical in nature. Based on this information, we decided that the Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pre-approve power seat elevation and standing 
features.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the kyphoplasty. 
 
You asked the Plan to pre-approve the kyphoplasty. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty is covered when criteria listed in 
Medicare Rules section 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 the kyphoplasty. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found detailed documentation is not evident 
regarding advanced imaging corroboration of an acute or subacute osteoporotic vertebral compression fracture. 
Additionally, there are plausible other causes of her pain as demonstrated in the provided lumbar imaging 
studies. The imaging studies did not corroborate there is no fracture retropulsion or canal compromise. No 
compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the kyphoplasty.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 
29, 2022, to September 30, 2022. 
 You asked the Plan to pay for the acute inpatient hospital care. You say that the enrollee's hospital stay, along 
with the services/procedures performed, were medically necessary. The Plan denied your request. The Plan 
says the information received does not support that criterion were met for an inpatient hospitalization. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for the acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the record did not show that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier 
emergency department and/or observation care) would span two midnights. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from September 29, 2022, to 
September 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nulojix (belatacept) (J0485). 
 
You asked the Plan to pre-approve Nulojix. You say that this should be covered via Part D benefits so the 
enrollee can receive home infusions. You say that the enrollee is having complications from kidney transplant. 
You also say that sending them to an outpatient infusion center is not the best approach. The Plan denied your 
request. The Plan says the requested drug is not covered when administered in the home setting. 
 
The Plan must follow Medicare rules. The rules say that parenteral belatacept is not proven to be safe when 
administered in the home setting and therefore will be denied as not medically necessary when provided in that 
setting.  
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Nulojix have not been met. Specifically, the requested drug is not covered when it is to be provided 
in the home setting. Therefore, we decided that the Plan does not have to pre-approve Nulojix (belatacept) 
(J0485).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA); respiratory virus (87631) provided on June 2, 2021. 
 
You asked the Plan to pay for the infectious agent detection by nucleic acid (DNA or RNA); respiratory virus. 
You say that this claim should be accepted. The Plan denied your request. The Plan says this claim was not 
filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the infectious agent detection by nucleic acid (DNA or RNA); respiratory 
virus was not filed until November 22, 2022. This means that more than one calendar year from the date of 
service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the 
infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (87631) provided on June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for alveoloplasty with extractions (D7310) provided on April 21, 
2022. 
 
You asked the Plan to pay for alveoloplasty with extractions. You say that this should be covered. The Plan 
denied your request. The Plan says this 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 Plans 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 
alveoloplasty with extractions (D7310) provided on April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on November 14, 2022. 
 You asked the Plan to pay for the refraction. You say that you were not informed that the refraction was not a 
part of the standard exam. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 these services when performed as a part of the routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was not performed with a routine eye 
exam. The record shows the refraction was performed during a medical eye exam. Based on this information, 
we decided that the Plan's rules for coverage of the refraction have not been met. Therefore, we decided that the 
Plan does not have to pay for the refraction provided on November 14, 2022.  
 
Your complaint about the benefit design is not a valid appeal for medical coverage. This part of your complaint 
is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these 
types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on November 4, 
2022. 
 
You asked the Plan to pay for the services provided. You say that no contracting provider had what you 
needed. The Plan denied your request. The Plan says the provider is not in your network. 
 The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
The file shows that a knee walker was provided. A review of the file and Medicare records indicates that the 
provider at issue is not enrolled in the Medicare program. The Plan did not pre-approve the service at issue. We 
found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does 
not have to pay for the durable medical equipment provided on November 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service October 21, 
2022. 
 You asked the Plan to pay for procedure code 86077. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service October 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reline of a complete upper denture (D5750) provided on 
November 14, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are requesting a discount on your claim and 
the removable dentures are saving you from being in pain. The Plan denied your request. The Plan says the 
denial of payment for this service is correct, because the reline of a complete upper denture is not covered by 
the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the reline 
of a complete upper denture (D5750) provided on November 14, 2022.
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 you are requesting reconsideration for the denial of 
an IRF admission. You say you need acute rehabilitation as soon as possible. The Plan denied your request. 
The Plan says you do not meet the requirements for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H2036 billed for date of service October 16, 
2022, to October 18, 2022. 
 
You asked the Plan to pay for procedure code H2036. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 
 We find that procedure code H2036 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code H2036 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code H2036 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code H2036 billed for date of service October 16, 2022, to October 18, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99457 billed for date of service September 7, 2022. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports medical necessity. 
The Plan denied your request. The Plan says that the code exceeds the number/frequency allowed within a time 
period. 
 
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 MUE for CPT code 99457 is 1. The MAI value for this code is 2. You billed 1 unit of this 
code. An MUE is the maximum units of service reported for a code by the same provider for the same 
beneficiary on the same date of service. Based on this information, we decided that Medicare rules for coverage 
of the billed services have been met. Therefore, we decided that the Plan has to pay for procedure code 99457 
billed for date of service September 7, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Optimizer Smart implantable pulse generator. 
 
You asked the Plan to pre-approve Optimizer Smart procedure. You say that this will enhance the strength of 
ventricular contraction and therefore heart pumping capacity. The Plan denied your request. The Plan says the 
clinical value and effectiveness of this device have not been demonstrated. 
 
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 Optimizer Smart procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this procedure remains the subject of multiple studies examining long-term 
efficacy. Until such studies are completed, it is premature to presume clinical outcomes and benefits. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Optimizer Smart procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Optimizer Smart implantable pulse generator.