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

 
We decided that the Plan does not have to pay for a power wheelchair purchased on September 13, 2021. 
 
You asked the Plan to pay for a power wheelchair. You say that you need this item. The Plan denied your 
request. The Plan says this item was purchased through a provider that is not enrolled with Medicare. 
 
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. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a power wheelchair purchased on 
September 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the myPath melanoma test provided on August 19, 2021. 
 
You asked the Plan to pay for the myPath melanoma test. You say that this test was medically necessary. The 
Plan denied your request. The Plan says this test was requested to differentiate between malignant melanoma 
and Bapoma. Medical literature shows no evidence of support the use of this test 
 
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 pay for the myPath melanoma test. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the results of this test are suggestive rather than decisive, so it is not medically 
necessary and reasonable. 
 
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 myPath melanoma test have not been met. Therefore, we decided that the 
Plan does not have to pay for the myPath melanoma test provided on August 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on November 
18, 2021. 
 
You asked the Plan to pay for the testing services. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code 73706 is computed tomographic angiography, lower 
extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing.  
 
We looked at the file and the rules. We find that CPT code 73706 may be eligible for payment when billed with 
CPT code 74174. The claim provided does not show that the code at issue was billed with a modifier suitable 
for payment. Based on this information, we decided that Medicare rules for coverage of the testing services 
have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography 
(CT) scan provided on November 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and pressure 
pneumatic appliance (E0673). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the pneumatic compression device and/ or supplies is not covered 
by Medicare to prevent deep vein thrombosis during and/or following surgery, at home, or in any setting. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and pressure pneumatic appliance (E0673).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need the therapy in order to function properly. 
You feel that your needs will be better met at a rehabilitation center versus at a skilled nursing facility (SNF). 
The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage. 
 
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 your rehabilitation needs can be met at a lower intensity setting such as in a SNF. 
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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that these services are contraindicated for the enrollee. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The vertiflex device 
is experimental. More research is needed. Our physician reviewer found that the enrollee's condition does not 
meet criteria for coverage of these services. 
 
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 the Vertiflex Superion Interspinous device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
November 11, 2021. 
 
You asked the Plan to pay for the comprehensive exam. You say that you are upset that this service is not being 
covered, and you feel you have been cheated. The Plan denied your request. The Plan says you had a previous 
comprehensive oral exam in April of 2021, which was covered by the Plan at that time. This service is only 
covered once every three years. 
 
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 can cover one 
periodontal exam or one comprehensive oral exam every three years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the comprehensive exam is requested 
in a frequency that is not covered under this benefit. Therefore, we decided that the Plan does not have to pay 
for the comprehensive oral evaluation (D0150) provided on November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services (98940) provided on September 15, 
2021 to September 20, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says these services were not urgent, emergent or 
approved in advance. 
 
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 the chiropractic services (98940) provided on 
September 15, 2021 to September 20, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye exam provided on August 
20, 2021. 
 
You asked the Plan to waive the copayment for a medical eye exam. You say that you have never charged a 
copayment for this exam before. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
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 $45 
copayment for eye exams that diagnose and treat diseases and conditions of the eyes.  
 
The records show your eye exam was to treat an existing issue you were having. You have been asked to pay a 
$45 copayment for a medical eye exam. A medical eye exam falls within the Vision 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 a medical eye exam provided on August 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on February 15, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0483-90 (1 Unit) remains not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 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 drug testing services provided to the enrollee on February 15, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of finger splint (29130) provided on August 
11, 2021. 
 
You asked the Plan to pay for the application of finger splint (29130). You say that the attached medical 
records support the visit. You say that you disagree with the determination as the service was appropriately 
billed. The Plan denied your request. The Plan says this service is included in the global package. 
 
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 29130 is application of finger splint; static. 
 
We find that CPT code 29130 is not supported in the medical record. Specifically, CPT code 26770 has a 
global period of 90 days. CPT code 29130 was billed within these 90 days by the same provider. There is no 
indication that these services are unrelated. Based on this information, we decided that Medicare rules for 
coverage of the application of finger splint (29130) have not been met. Therefore, we decided that the Plan 
does not have to pay for the application of finger splint (29130) provided on August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this service is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is a 69-year-old male who is being treated for other intervertebral 
disc degeneration lumbar region. He presented with has pretty severe back pain, axial in nature, any type of 
prolonged sitting accentuates the pain. Height is 69 inches, weight 155 pounds, and body mass index is 22.89 
kg/m2. Exam reveals tenderness to palpation at the middle/lower lumbar spine. Lumbar range of motion is 
decreased. Strength, sensation and reflexes are intact. However, detailed documentation is not evident 
regarding Modic type changes on the radiologist's read of the lumbar magnetic resonance imaging. 
Additionally, in this case, there were/are multiple plausible pathologic sources of significant pain generation. Overall, documentation was/is lacking regarding reasonably detailed and/or evidenced findings supportive of 
the spinal vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent 
pain. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the request for Intracept intraosseous nerve ablation system 
at L5 and S1 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a high strength, lightweight manual wheelchair (K0004). 
 
You asked the Plan to pay for a high strength, lightweight manual wheelchair. You say that the item is 
medically necessary. The Plan denied your request. The Plan says Medicare coverage rules for DME do not 
allow for the direct purchase of wheelchairs, only covering rent-to-purchase of the equipment following the 
Medicare-defined rental period. Medicare coverage rules also state that a beneficiary must use eligible 
providers enrolled in the Medicare program for their services to be covered. 
 
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. 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a high strength, lightweight manual 
wheelchair (K0004).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence that this device is safer and more effective than a standard assistive 
device for ambulation such as regular crutches. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the request for E0118 exceeds your medical needs, and do not meet the medical necessity criteria. The 
documentation does not reveal an objective physical examination indicating that you are unable to use standard 
crutches, or that you can safely use the E0118. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a crutch substitute.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for items billed with codes S1015 and S8301 for date of service 
September 15, 2021. 
 
You asked the Plan to pay for codes S1015 and S8301. You say that your organization provided these items at 
your own cost and they should be paid. The Plan denied your request. The Plan says these services were billed 
with invalid codes. 
 
The Plan must follow Medicare rules. Medicare rules say that codes with a status indicator of 'E1' are not paid 
by Medicare when billed on any outpatient bill type.  In this case, codes S1015 and S8301 both have a status 
indicator of E1 and were billed on an outpatient bill. Based on this information, we decided that Medicare rules 
for coverage of codes S1015 and S8301 have not been met. Therefore, we decided that the Plan does not have 
to pay for items billed with codes S1015 and S8301 for date of service September 15, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 12, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided on November 12, 2020.
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 are a fall risk and are unable to perform daily 
functions of living and need SNF care in order to regain function. The Plan denied your request. The Plan says 
you do not meet Medicare criteria for coverage. 
 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 daily 
skilled services are not necessary. Our physician reviewer found 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 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 pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee had a hip replacement and has other 
issues that require acute rehabilitation. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare criteria for coverage. 
 
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 your rehabilitation needs can be met at a lower intensity setting such as in-home or in 
a skilled nursing facility (SNF). 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 IRF admission and services.