Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services (81479) provided on June 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that this claim should be paid. The Plan denied your 
request. The Plan says that this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Specifically, there was a lack of evidence of prior 
payment for the claim at issue. Based on this information, we decided that Medicare rules for coverage of the 
lab services have been met. Therefore, we decided that the Plan has to pay for the lab services (81479) 
provided on June 21, 2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sunscreen provided on April 2, 2022. 
 
You asked the Plan to pay for the sunscreen. You say that you want to be reimbursed for the sunscreen. The 
Plan denied your request. The Plan says the OTC benefit was applied to your OTC care and no out-of-pocket 
money was spent. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
sunscreen is an OTC item. The record shows you purchased the sunscreen with your OTC card. Therefore, we 
decided that the Plan does not have to pay for the sunscreen provided on April 2, 2022.  
 
Your complaint about the defective product 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 pre-approve a Group 3 power wheelchair (PWC) with multiple 
power options, including a power tilt and recline seating system. 
 
You asked the Plan to pre-approve the requested Group 3 PWC. You say that it is felt that the enrollee's 
condition does require both power tilt and recline. The Plan denied your request. The Plan says there is no 
evidence that the enrollee's needs cannot be met with power tilt alone. As such, the multiple power options 
PWC base does not meet criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with multiple power options may 
only be covered when the enrollee meets criteria for a power tilt and power recline seating system. 
 
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 requested Group 3 PWC. Our 
reviewer says that the requested PWC with multiple power options does not meet Medicare criteria. Our physician reviewer found the enrollee has a neurologic disorder with functional deficits. The documentation 
does not indicate that the enrollee has any current pressure injuries involving the trunk or pelvis or requires 
intermittent catheterization of the bladder that would necessitate power tilt and recline. As such, the requested 
PWC base cannot be covered per coverage rules. 
 
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 requested Group 3 PWC have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple power options, including 
a power tilt and recline seating system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI) (62321). 
 
You asked the Plan to pre-approve the ESI. You say that you have pain, numbness and tingling from the base 
of your skull to the tips of your fingers. You say that this has been happening for 6 months. You also say that you already have an appointment set for this. The Plan denied your request. The Plan says the requested 
injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when all the 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 the ESI. Our reviewer says that the 
requested ESI is not medically necessary. Our physician reviewer found the provided imaging does not indicate 
central disc herniation, osteophyte or osteophyte complexes, or severe degenerative disc disease that produces 
foraminal or central spinal stenosis. Therefore, the reviewer found that the requested ESI is 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 the ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an epidural steroid injection (ESI) (62321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness for upgrade to expandable controller (E2313) 
and an expandable controller (E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested accessories are 
medically necessary. The Plan denied your request. The Plan says although there are three approved power 
options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these 
power options through the joystick. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found an expandable controller is an electronic system that is capable of accommodating 
one or more additional features and can operate 3 or more powered seating options. In this case, the enrollee 
has a neurologic disorder with functional deficits. Criteria for a power wheelchair are met. The requested 
electrical accessories are not medically necessary as the enrollee does have use of the upper extremity and can 
operate and control the power options using the switches that are included in the basic wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness for upgrade to expandable controller (E2313) and an expandable 
controller (E2377).
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. The Plan denied your request. The Plan says that the coverage 
criteria has not been met. 
 
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 the documentation does not support medical necessity for admission to an IRF. 
The enrollee has no medical complexity, and no rehabilitation nursing needs other than routine nursing care. 
While the enrollee may benefit from physical therapy and occupational therapy, the enrollee's rehabilitation needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry services. 
 
You asked the Plan to pre-approve external mobile cardiovascular telemetry services. You say that the patient 
has chest pain and palpitations that lasted up to 5 minutes and it is unable to be caught on regular EKG tracing 
in the clinic. You say that a Holter monitor was ordered prior to the patient being cleared for surgery to rule out 
irregular heart rate. The Plan denied your request. The Plan says the external mobile cardiovascular telemetry 
services do not meet the requirements for approval. 
 
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 external mobile cardiovascular 
telemetry services. Our reviewer says that the requested external mobile cardiovascular telemetry services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee 
has a history of frequent palpitations, and this was the stated indication for mobile cardiac outpatient telemetry 
(MCOT) authorization. As such, guidelines would not support a need for MCOT monitoring in this setting. In 
summary, there was insufficient documentation to support the medical necessity for an MCOT monitor in this 
enrollees clinical management.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of external mobile cardiovascular telemetry services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tizanidine HCL. 
 
You asked the Plan to pre-approve Tizanidine HCL. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 Tizanidine HCL.  
 
Benefits for Tizanidine HCL 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided from 
September 16, 2022, through September 19, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered benefit. 
 
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 provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(A9270) provided from September 16, 2022, through September 19, 2022.  
 Benefits for these items 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 pre-approve a thermal destruction of intraosseous basivertebral 
nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628). 
 
You asked the Plan to pre-approve an Intracept Procedure. You say that you disagree with the denial for 
intraosseous ablation of the basivertebral nerve, which is accomplished with the lntracept Procedure. This 
procedure fills a treatment gap for those enrollees that do not receive adequate relief from traditional 
conservative methods and don't have instability to indicate fusion is the appropriate treatment. You say the 
procedure is medically necessary and supported by strong science. 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 an Intracept Procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental and investigational for back pain. More 
research is needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept Procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first 2 vertebral bodies, lumbar or sacral (64628).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants on tooth #6, 11, and 12 (D6010). 
 
You asked the Plan to pre-approve implants. You say that the implants are medically necessary. The Plan 
denied your request. The Plan says that the coverage criteria has not been met. 
 
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 Plan covers implants 
when the services are medically necessary and reasonable.  
 
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 implants. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that the documentation provided does not 
meet the criteria for coverage for endosteal implants. There is no indication of exceptional medical conditions 
in this case. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of implants have not been met. Therefore, we decided that the Plan does not have 
to pre-approve endosteal implants on tooth #6, 11, and 12 (D6010).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided on July 13, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for hospital services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says these services were provided by an out-of-network provider. 
 
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 had network providers 
available who could have provided 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 hospital services provided on July 13, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the denture for lower arch (D5868). We decided that the Plan does 
not have to pre-approve the implants (D6010) for tooth #23 and #26.  
 
You asked the Plan to pre-approve a denture for lower arch (D5868) and implants (D6010) for tooth #23 and 
#26.. You say that the dental procedures are medically necessary. The Plan says that the x-rays the enrollee's 
dentist sent do not show that the enrollee has implants in their mouth to hold the denture in place. Also, the 
denial of authorization for the implants is correct, because they are not covered by the Plan. 
 We decided that the Plan has to pre-approve the denture for lower arch (D5868).  
 
The Plan follows Medicare rules. Medicare rules say that 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. 
 
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 dental services. Our reviewer says 
that the denture for lower arch is medically necessary. Our physician reviewer found that the documentation 
provided verifies that dental implant services are not covered expenses. Complete dentures, including 
overdentures are covered expenses according to the EOC. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve a denture for lower arch (D5868). 
 
We also decided that the Plan does not have to pre-approve the implants (D6010) for tooth #23 and #26. 
 
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 
implants (D6010) for tooth #23 and #26. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service July 3, 2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 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, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service July 3, 2022.