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

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve RFA. You say that the services are necessary. The Plan denied your request. 
The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that if there is an extended period of time, two years or 
more, since the last RFA and/or there is a question as to the source of the recurrent pain then diagnostic 
procedures must be repeated. 
 
 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 RFA. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there has been an extended period of time 
(three years) since the last RFA. The enrollee has not undergone repeated diagnostic medial branch blocks at 
these sites to confirm source of pain. Therefore, until the diagnostic blocks are repeated, the request is 
considered 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 RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on January 12, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that the government should be 
paying for this, not you. It was for a covid test. The Plan denied your request. The Plan says the copayment was 
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 $55 
copayment for urgently needed services.  
 
You have been asked to pay a $55 copayment for an urgent care visit. An urgent care visit falls within the 
Urgently Needed Services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an urgent 
care visit provided on January 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments a wound debridement provided on June 1, 
2022, and June 9, 2022. 
 
You asked the Plan to waive the copayments a wound debridement. You say that you should not have this large 
of a copayment. The Plan denied your request. The Plan says the copayment that was applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. You had two procedures, each has a copayment of $250, totaling $500 ($250 x 2 = $500). 
 
You have been asked to pay a $500 copayment for a wound debridement. A wound debridement falls within 
the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. This means that you have been asked to pay the correct amount based on 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 copayments a wound debridement provided on June 1, 2022, 
and June 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a respiratory assist device provided from 
June 20, 2021, to January 20, 2022. 
 
You asked the Plan to waive the coinsurance for a respiratory assist device. You say that this cost will cause a 
financial hardship. The Plan denied your request. The Plan says the copayment that was applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment (DME) and related supplies. The allowed amount of this item is 
$102.51 resulting in a $20.50 coinsurance ($102.51 x 20% = $20.50). $20.50 x 5 months = $102.51. 
The allowed amount of this item is $76.88 resulting in a $15.38 coinsurance ($76.88 x 20% = $15.38). 
 
You have been asked to pay a $117.88 ($15.38 + $102.51 = $117.88) coinsurance for a respiratory assist 
device. A respiratory assist device falls within the Durable Medical Equipment (DME) and Related 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 coinsurance for a respiratory assist device 
provided from June 20, 2021, to January 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for mammography diagnostic testing provided 
on June 6, 2022. 
 
You asked the Plan to waive the copayment for mammography diagnostic testing. You say that this copayment 
is too high, and you cannot afford it. The Plan denied your request. The Plan says the copayment that was 
applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $101.80 copayment, rather than the full copayment amount of $150 for 
mammography diagnostic testing. Mammography diagnostic testing falls 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 copayment for mammography diagnostic testing provided on 
June 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room admission and 
inpatient stay provided from May 23, 2022, to May 31, 2022. 
 
You asked the Plan to waive the copayment for an emergency room admission and inpatient stay. You say that 
you weren't even put into a room, you were just in observation. The Plan denied your request. The Plan says 
you were charged this cost sharing 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 $210 
copayment per for days 1-6 per admission for inpatient hospital care and a $90 copayment for emergency care. 
$1,260 maximum + $90 for ER = $1350 total copayment.  
 
You have been asked to pay a $1350 total copayment for an emergency room admission and inpatient stay. An 
emergency room admission and inpatient stay falls within the Emergency Care and Inpatient Hospital Care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room admission 
and inpatient stay provided from May 23, 2022, to May 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated seat cushion represented by code 
E2609, a custom fabricated back cushion represented by code E2617, an expandable controller represented by 
code E2377, an access harness for an expandable controller represented by code E2313, and an electronic 
connection represented by code E2311. 
 
You asked the Plan to pre-approve codes E2609, E2617, E2377, E2313 and E2311. You say that the records 
provided support the need for the items which remain in dispute. The Plan denied your request. The Plan says 
the notes do not clearly explain why a prefabricated seating system is not sufficient to meet your needs. The 
Plan says that the notes do not clearly explain why a positioning back cushion is not sufficient to meet your 
needs. The Plan says that there is no documentation of fixed deformity for which position back cushion would 
be insufficient. The Plan says that the approved power options come with their own switches. The Plan says 
that your bilateral upper limb strength and range of motion is documented to be normal and adequate for you to 
be able to control the power options using 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 codes E2609, E2617, E2377, E2313 
and E2311. Our reviewer says that the requested items are not considered medically reasonable and necessary 
in this case. Our physician reviewer found you do not require a ventilator, or non-proportional input devices. 
You do not require a separate display, other electronic devices, or an attendant control. You have power 
options on the wheelchair, but you do not need to control the power options through a joystick. Your upper 
extremity function with independence in upper body dressing with set up supports that you can control any power options through your own switches. Additionally, a T4 level spinal cord injury should have sufficient 
hand strength that would not require these features as the hand muscles are innervated by myotomes proximal 
to this injury level.  The documentation does not support why a prefabricated seating system, or a prefabricated 
positioning back cushion is not sufficient to meet your needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes E2609, E2617, E2377, E2313 and E2311 have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a custom fabricated seat cushion represented by code 
E2609, a custom fabricated back cushion represented by code E2617, an expandable controller represented by 
code E2377, an access harness for an expandable controller represented by code E2313, and an electronic 
connection represented by code E2311.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3 foot represented by code L5987. 
 
You asked the Plan to pre-approve code L5987. You say that your current foot is broken, and this is dangerous. 
You say that the records provided support that the requested foot is medically necessary. The Plan denied your 
request. The Plan says the notes do not support the need for a K3 foot. The Plan says that the records indicate 
the enrollee was approved for a scooter in Marcy of 2022. The Plan says that this is not consistent with K3 
ambulation as a scooter is only allowed for persons unable to perform mobility related activities of daily living 
at home without a power operated vehicle. The Plan says that this is inconsistent with K3 ambulatory function. 
The Plan says that a request for a K2 foot that meets the enrollee's needs and Medicare guidelines can be 
reviewed if submitted. 
 
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 code L5987. Our reviewer says that the 
item which remains in dispute is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the clinical documentation of functional need for the L5987 has not been met. The 
documentation does not support that the patient is a K3 level given the documentation that indicates he was 
approved for a motorized scooter. Additionally, the requested foot is the Rush Rogue 2 Evaqu8 foot. A review 
of this foot online indicates that this foot includes an elevated vacuum system.  This exceeds the enrollee's 
medical needs. An elevated vacuum system does not meet Medicare medically necessary criteria, as Medicare 
does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of 
illness or injury or to improve the functioning of a malformed body member.  The literature reviewed indicates 
that further research is needed with clinical trials that recruit larger sample sizes and report long-term outcome 
data for elevated vacuum systems. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code L5987 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a K3 foot represented by code L5987.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an all-lower extremity prosthesis, foot, flexible keel 
(L5972) and an all-lower extremity prosthesis, multi-axial rotation unit (L5986). 
 
You asked the Plan to pre-approve prosthetics. You say that the requested components will assist the enrollee, 
given his physical stature, to provide stability while he ambulates, and reduce his fall risk. The Plan denied 
your request. The Plan says the requested K2 components exceed the enrollee's needs and cannot be covered. 
 
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 prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested items exceed the enrollee's medical needs. Medicare does not pay for any items or 
services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve 
the functioning of a malformed body member. The physician documentation does not support that the enrollee 
will be a K2 ambulator given his significant comorbidities, current functional level, and the documentation 
indicating that he is looking to be a household ambulator at K1. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an all-lower extremity prosthesis, foot, flexible keel (L5972) and an all-lower extremity 
prosthesis, multi-axial rotation unit (L5986).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown repair on tooth #15 (D2980) and core build up on 
tooth #15 (D2950). 
 
You asked the Plan to pre-approve crown repair and core build up. You say that you disagree with the denial of 
dental services. The Plan denied your request. The Plan says crown repair (D2980) and core build up (D2950) 
are not covered by your dental 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. 
 
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 
crown repair on tooth #15 (D2980) and core build up on tooth #15 (D2950).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20680 and 11044 billed for date of service 
July 4, 2020. 
 You asked the Plan to pay for procedure code 20680. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 20680 is bundled into payment for code 27245. 
 
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 20680 
is a column II code to column I code 27245. 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.  
 
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 11044 is debridement, bone (includes epidermis, dermis, 
subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less. 
 
We find that CPT code 11044 is not supported in the medical record. Specifically, the documentation does not 
contain the total surface area measurements for the wound debridement. Based on this information, we decided 
that Medicare rules for coverage of these services have not been met. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 20680 and 11044 billed for date 
of service July 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immediate upper denture (D5130), an extraction, 
erupted tooth or exposed root (D7140) and an extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth (D7210). 
 
You asked the Plan to pre-approve the dental services. You say that you are having pain in your teeth, causing 
you to have trouble chewing. You are asking the plan to review and reconsider coverage. The Plan denied your 
request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve an 
immediate upper denture (D5130), an extraction, erupted tooth or exposed root (D7140) and an extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth (D7210).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the multiaxial rotation unit (L5986). 
 
You asked the Plan to pre-approve the multiaxial rotation unit. You say that the requested equipment is 
medically reasonable and necessary for your condition. The Plan denied your request. The Plan says that the 
requested multi axial rotation unit exceeds the enrollee's needs. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary. Medicare rules say that an 
axial rotation unit (L5982, L5984, L5985, L5986) is covered for beneficiaries whose functional level is 2 or 
above. 
 
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 multi axial rotation unit. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found that you are a 60-year-old male with a medical history of peripheral artery 
disease, diabetes mellitus type II and chronic kidney disease. You underwent a left transtibial amputation in 
April of 2022 due to osteomyelitis. A prosthetic evaluation note dated July 6, 2022, indicated that you are a K2 
level ambulator. A prosthetic note dated July 25, 2022, indicated that you ambulated 200 feet in the parallel 
bars. You are noted to have full active range of motion and his contralateral limb has sufficient strength to 
ambulate with a prosthesis. The documentation provided does support the use of the multiaxial rotation unit for 
your preparatory prosthesis and that you have the potential to be a K2 level ambulator.  
 
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 multi axial rotation unit have been met. Therefore, we decided that the Plan 
has to pre-approve the multiaxial rotation unit (L5986).  
 
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 seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the requested wheelchair accessory is statutorily not covered 
under Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation system is not covered 
because they are not primarily medical in nature. 
 
While a power seat elevation system may be appropriate in this case, neither the Plan nor Medicare offers 
coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation 
system (E2300).