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

 
We decided that the Plan does not have to pay for a manual wheelchair purchased June 2, 2022. 
 
You asked the Plan to pay for a wheelchair. You say that because you fractured your hip, you purchased a 
manual wheelchair. Once the doctors deemed it safe for you to fly home, you purchased the wheelchair to 
assist in your mobility. The Plan denied your request. The Plan says there is insufficient documentation to 
corroborate the services and confirm Medicare coverage has been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a wheelchair have been met. 
Additional information and records were needed. The Plan made multiple attempts to obtain the additional 
information from the provider without success. Therefore, we decided that the Plan does not have to pay for a 
manual wheelchair purchased June 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code(s): 22869 and 22870). 
 
You asked the Plan to pre-approve the service. You say that the enrollee is in severe pain and have exhausted 
all other treatment options. The Plan denied your request. The Plan says unproven and not medically necessary 
procedures are not covered by Medicare due to insufficient evidence of efficacy. 
 
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 service. 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 compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested Vertiflex superion interspinous 
spacer at L3-4 and L4-5, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the out-of-area office visit (99214) provided on August 12, 2022. 
 
You asked the Plan to pay for the outpatient service. You say that you were bit on the ankle by a dog. You say 
that the nearest hospital was 40 minutes away. You say there was a walk-in clinic 17 minutes away. You say 
that you felt this was an emergency. You also say that you were not sure if the dog was rabid or not. The Plan 
denied your request. The Plan says that prior authorization was not obtained. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
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 physician service. Our reviewer says that 
the physician service was medically necessary. Our physician reviewer found the provided documentation 
indicates that you could not have foreseen requiring the services prior to leaving your service area. The 
reviewer found that the records indicate that the care provided was an emergency and medically necessary as 
the walk-in clinic was the closest reasonable location to receive care. Therefore, the reviewer found that the 
service in this case was 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 physician service have been met. Therefore, we decided that the Plan has to 
pay for the out-of-area office visit (99214) provided on August 12, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair accessory, electronic connection 
between wheelchair controller and one power seating system motor (E2310). 
 
You asked the Plan to pre-approve a power wheelchair accessory. You say that you disagree with the denial. 
The Plan denied your request. The Plan says there is not a medical need to control these power options through 
the joystick. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 The file shows that the enrollee is not complaint with following orders of not using her arms to lift herself. The 
file also shows that the enrollee can control the power options using their own switch which is included in the 
allowance of these power options. This means that Medicare rules for coverage of a wheelchair accessory have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair accessory, 
electronic connection between wheelchair controller and one power seating system motor (E2310).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service from 
August 13, 2022, to September 9, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that the services at issue have been billed 
correctly. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service from August 13, 2022, to September 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), 
and first intraoral periapical x-ray (D0220) provided on August 16, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the dental services. You say that you are aware the provider is OON, but you go 
to their office for continuity of care and would like to appeal in order to get the claim paid. The Plan denied 
your request. The Plan says the dental services were received from an out-of-network provider and are not 
covered by your supplemental benefits. 
 
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. 
 
 
 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), and first intraoral periapical x-ray 
(D0220) provided on August 16, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 17, 2021, at 
the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services were reported correctly and are supported as billed. The Plan denied your request. The Plan says the 
DRG submitted on this claim 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 inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with sepsis, unspecified organism (A41.9). 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 inpatient hospital services at the DRG originally billed. 
Our reviewer says that this diagnosis is not supported in the medical record. Our physician reviewer found 
there was no clinical or laboratory evidence of sepsis. The enrollee was hemodynamically stable throughout the 
hospitalization. The review has determined that the documentation did not support A41.9.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 17, 2021, at the Diagnosis Related Group (DRG) originally 
billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92235 billed for date of service January 3, 
2022. 
 
You asked the Plan to pay for procedure code 92235. You say that these services were necessary and reported 
appropriately. The Plan denied your request. The Plan says this service is not supported as billed as no 
documentation was included to support that multiframe images were obtained to support this code. 
 
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 92235 is fluorescein angiography (include multiframe imaging) with interpretation and report, unilateral 
or bilateral. 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 procedure code 92235. Our reviewer says that this service is 
not supported in the medical record. Our reviewer found the procedure report describes fluorescein 
angiography with interpretation and report. In this case, there is a more appropriate code to bill, as multiframe 
imaging is not supported in the medical record. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 92235 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 92235 billed for date of service January 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the addition to lower limb prosthesis, vacuum pump, 
residual limb volume management and moisture evacuation system (L5781) all endoskeletal lower extremity 
prosthesis, axial rotation unit, with or without adjustability (L5984) all lower extremity prosthesis, shank foot 
system with vertical loading pylon (L5987). 
 
You asked the Plan to pre-approve the K3 foot and ankle and advanced suctions system. You say that you 
request for review of the clinical file included in this submission and overturn the partial denial of the shank 
foot L5987 and L5987 and volume management system L5781. The Plan denied your request. The Plan says 
the requested prosthesis exceeds the enrollee's needs. The vacuum socket is unproven and not medically 
necessary due to insufficient evidence of safety and/or efficacy. 
 
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 K3 foot and ankle and advanced 
suctions system. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found for procedure codes L5984, axial rotation unit, with 
or without adjustability and L5987, shank foot system with vertical loading pylon exceeds the enrollees 
medical needs and is not medically necessary. The treating medical physician provider documentation does not 
support that the enrollee is a K3 ambulator. The enrollee is using a walker for shorter distances and a 
wheelchair for community distance which does not support a K3 level of ambulation. Procedure code L5781, 
vacuum pump, residual limb volume management and moisture evacuation system exceeds the enrollees 
medical needs and is not proven superior to a standard socket, therefore does not meet Medicare medically 
necessary criteria.  Per documentation the recommendation is for an elevated vacuum system.  The literature 
reviewed indicates that further research is needed with clinical trials that recruit larger sample sizes and report 
long-term outcome data for the requested vacuum suspension system. 
 
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 K3 foot and ankle and advanced suctions system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the addition to lower limb prosthesis, vacuum 
pump, residual limb volume management and moisture evacuation system (L5781) all endoskeletal lower 
extremity prosthesis, axial rotation unit, with or without adjustability (L5984) all lower extremity prosthesis, 
shank foot system with vertical loading pylon (L5987).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 27, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve Ozempic. You say that this will help regulate the enrollee's multiple 
medications. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition 
under 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 Ozempic.  
 
 Benefits for Ozempic 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 pre-approve the male vacuum erection system (L7900 X2). 
 
You asked the Plan to pre-approve the item. You say that the item is necessary. The Plan denied your request. 
The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Vacuum erection devices 
(L7900) and related accessories (L7902) are statutorily non-covered. Based on this information, we decided 
that Medicare rules for coverage of the item have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the male vacuum erection system (L7900 X2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 8, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation to the sacroiliac joint (64625). 
 
You asked the Plan to pre-approve a radiofrequency ablation to the sacroiliac joint. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of 
radiofrequency ablation to the SI joint in the setting of sacroiliitis have not been demonstrated in the peer-
reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a radiofrequency ablation to the 
sacroiliac joint. Our reviewer says that the requested service is not considered medically reasonable and 
necessary in this case. Our physician reviewer found this service is considered experimental and more research 
is needed to show its safety and efficacy. 
 
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 radiofrequency ablation to the sacroiliac joint have not been met. Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation to the sacroiliac joint (64625).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 91040 provided on April 13, 2022. 
 
You asked the Plan to pay for procedure code 91040. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Medicare says that the OCE will return to the provider any claim that 
reports a HCPCS code for a procedure assigned to a device-intensive APC, for which the procedure requires 
the implantation of a device that does not also report at least one device HCPCS code required for that 
procedure. In this case, Medicare procedure/device coding requirements have not been met as procedure code 
91040 must be reported with a qualifying device code. Therefore, we decided that the Plan does not have to pay 
for procedure code 91040 provided on April 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a controller connection (E2311). 
 
You asked the Plan to pre-approve a controller connection. You say that this is medically necessary. The Plan 
denied your request. The Plan says the power options can be controlled with their own switches. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a controller connection. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not need to control the power options through a joystick. The enrollee's upper 
extremity strength supports that the patient can control any power options through their own switches. 
 
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 controller connection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a controller connection (E2311).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Testopel. 
 
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 Testopel 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 
the services are not medically necessary. Our physician reviewer found the enrollee has a reported diagnosis of 
hypogonadism and is receiving intramuscular testosterone replacement. The records document a single normal 
testosterone level. The records do not indicate levels of luteinizing hormone (LH) and follicle stimulating 
hormone (FSH). The records are insufficient to support that the criteria are met; therefore, the services are not 
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 Testopel.