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

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options 
 
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 need for multiple power options. 
 
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.  
 
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 medically reasonable or necessary. Our physician reviewer found that although there 
is a letter of medical necessity and various vendor-generated forms arguing medical necessity of the group 3 
power wheelchair with multiple power options and accessories, the provided medical records do not include a 
face to face examination with the patient's physician or medical provider which explains the necessity of 
requested components of the group 3 power wheelchair with multiple power options as required by the Local 
Coverage Determination (LCD): Power Mobility Devices L33789. 
 
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 group 3 power wheelchair with multiple power options
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lead, neurostimulator (C1778), and percutaneous 
implantation of neurostimulator electrode array (64555). 
 
You asked the Plan to pre-approve a SPRINT neurostimulator device. You say that the enrollee has tried and 
failed all conventional treatment options. You say that nothing has provided sustained pain relief. You also say 
that the pain is causing limitations in the enrollee's daily living. The Plan denied your request. The Plan says 
the requested device is not medically necessary. 
 
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 SPRINT neurostimulator device. Our 
reviewer says that the requested SPRINT neurostimulator device is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the requested SPRINT neurostimulator device is 
experimental for knee pain. The reviewer found there is not enough research to determine that the requested 
service is 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 a SPRINT neurostimulator device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a lead, neurostimulator (C1778), and percutaneous implantation of 
neurostimulator electrode array (64555).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 21 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that you feel you need more treatment because 
the type of therapy you need cannot be done at home. The Plan denied your request. The Plan says the records 
do not support this request for treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
 
 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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you have previously been treated with outpatient therapies and should 
be independent with a home exercise program. There is no documentation of a recent injury or decline in 
function. Our reviewer also found that the additional therapy services are not an appropriate duration and 
frequency for treatment of your medical condition and therefore 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 additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 21 additional physical therapy (PT) visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (0037U) provided on April 18, 2022. 
 
You asked the Plan to pay for the genetic testing. 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 to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted. 
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. 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 pay for the genetic testing 
(0037U) provided on April 18, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99233), and advanced 
care planning (99497) provided on February 22, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the enrollee's hospice benefit was revoked 
on February 21, 2022. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to 
verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 21, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent 
nursing facility care (99233), and advanced care planning (99497) provided on February 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the breast 
(77049). 
 
You asked the Plan to pre-approve the MRI. You say that you need the MRI because you are in pain, and you 
are high risk for cancer. The Plan denied your request. The Plan says medical necessity for a bilateral breast 
MRI scan is not supported per the guidelines, as there is no evidence of an abnormal breast ultrasound, 
abnormal mammogram, and abnormal clinical evaluation. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that an 
MRI is not medically necessary. Our physician reviewer found the provided documentation did not include any 
evidence of an abnormal breast ultrasound, abnormal mammogram, and abnormal clinical evaluation to justify 
follow-up with advanced imaging (MRI) at this time. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the breast (77049).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 29, 2021. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4649 and A4550 billed for date of service 
May 19, 2022. 
 
You asked the Plan to pay for procedure codes A4649 and A4550. You say that authorization was obtained 
prior to the services being rendered and the claim should be reprocessed for payment. The Plan denied your 
request. The Plan says procedure codes 64490 and 64491 have been paid. The Plan also says that procedure 
code A4649 and A4550 are 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 A4649 has a status indicator of P and procedure code A4550 has a status indicator 
of B on the Physician Fee Schedule. This means that procedure codes A4649 and A4550 are not separately 
payable. Based on this information, we decided that Medicare rules for coverage of procedure codes A4649 
and A4550 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
A4649 and A4550 billed for date of service May 19, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the copayment for x-rays provided on July 26, 2021. 
 
You asked the Plan to waive the copayment for x-rays. You say that you should not be responsible to pay this. 
The Plan denied your request. The Plan says that the cost share has been applied correctly applied. 
 
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 does not say in clear and accurate terms 
how much you should expect to pay for x-rays.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $30 
copayment for x-rays. The Plan contract does not clearly say how much enrollees must pay for x-rays. This 
means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we 
decided that the Plan has to waive the copayment for x-rays provided on July 26, 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 a limited oral evaluation (D0140), periapical x-rays (D0220, 
D0230), and endodontic therapy on tooth #9 (D3310) provided on May 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought these services would be covered. 
The Plan denied your request. The Plan says your benefit for a limited oral evaluation and periapical x-rays has 
already been exhausted. The Plan also says that endodontic therapy (D3310) is 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, endodontic therapy is not among those 
covered under this benefit. The record shows your benefit for a limited oral evaluation and periapical x-rays 
was exhausted on date of service March 22, 2022. Therefore, we decided that the Plan does not have to pay for 
a limited oral evaluation (D0140), periapical x-rays (D0220, D0230), and endodontic therapy on tooth #9 
(D3310) provided on May 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on February 23, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim was billed 
with the incorrect date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
 
 
 
 
 
 
 We find that payment for CPT code 81479 is not supported in the medical record. Specifically, the records 
show that the specimens were collected on November 29, 2021, and January 4, 2022. The lab services must be 
billed with the date of service that the specimen was collected. As such, the claim was billed with the incorrect 
date of service. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing provided on February 23, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa for the enrollee. 
 
You asked the Plan to pre-approve Euflexxa. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the member does not have a history of failure, contraindication, or intolerance to 
Durolane and Gelsyn-3. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that 
Euflexxa is not medically reasonable and necessary. The Plan requires a trial of Durolane and Gelsyn-3 before 
they will approve the requested drug. In this case, the patient has not tried and failed the required drugs. There 
is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or 
likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not 
meet step therapy criteria for Euflexxa. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 2, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. 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 November 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specimen validity testing provided to the enrollee on March 
4, 2022. 
 
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 the urine specimen was collected for drug testing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
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, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for specimen validity testing provided to the enrollee on March 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 25, 2022. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on January 25, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Orthovisc OR Supartz FX first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Euflexxa. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has osteoarthritis of the knee. The requested medication is a new start. The provided record states that 
the use of Supartz is acceptable. The provided records do not indicate that the enrollee has tried and failed the 
plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or 
would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage 
criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued rental payment for an oxygen concentrator 
and portable oxygen concentrator. 
 
You asked the Plan to pre-approve continued rental payment for an oxygen concentrator and portable oxygen 
concentrator. You say that this is medically necessary. The Plan denied your request. The Plan says that 
Medicare rules state oxygen equipment is limited to 36 months of rental. 
 
The Plan must follow Medicare rules. Medicare rules say that there is no further payment for oxygen 
equipment after 36 rental payments have been made.  
 
We looked at the file and Medicare rules. The file indicates that 36 rental payments have been made for your 
oxygen concentrators. Based on this information, we decided that Medicare rules for coverage of continued 
rental payment for an oxygen concentrator and portable oxygen concentrator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued rental payment for an oxygen concentrator and 
portable oxygen concentrator.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing services in a home health setting. 
 
You asked the Plan to pre-approve home health services. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for home health 
services have not been met. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
The file does not show that the enrollee is homebound. Therefore, we decided that the Plan does not have to 
pre-approve skilled nursing services in a home health setting.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the records provided support the need 
for a genicular nerve block. The Plan denied your request. The Plan says the requested type of injection 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 a genicular nerve block. Our reviewer 
says that a genicular nerve block is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered an experimental/investigational procedure whose role in the 
treatment of knee osteoarthritis is still being evaluated. 
 
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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.