Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026) provided on June 21, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that that there is sufficient evidence to conclude the 
use of infrared therapy devices and any related accessories is not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the infrared therapy service provided have not been met. Specifically, Medicare rules say that there is sufficient 
evidence to conclude that the use of infrared therapy devices and any related accessories is not reasonable and 
necessary. Therefore, we decided that the Plan does not have to pay for the infrared therapy (97026) provided 
on June 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter at-home COVID-19 tests purchased on 
September 22, 2022. 
 
You asked the Plan to pay for at-home COVID-19 tests. You say that you would like to be reimbursed for these 
tests. The Plan denied your request. The Plan says coverage for these services is provided through Original 
Medicare and not the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and at-home 
COVID-19 tests is an OTC item which is not offered directly through your Plan. Although limited Medicare 
coverage for at-home COVID-19 tests began on April 4, 2022, this benefit is offered through Original 
Medicare and requires the use of your Original Medicare card (the red, white and blue card) at the time of 
purchase. These services are not offered through your Medicare Advantage Plan and are not reimbursable by 
the Plan. Therefore, we decided that the Plan does not have to pay for over-the-counter at-home COVID-19 
tests purchased on September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial ostectomy/sequestrectomy (D7550) provided on 
October 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within 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 Plan's 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 pay for a partial 
ostectomy/sequestrectomy (D7550) provided on October 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upgraded components for a prosthesis described by 
codes L5981 and L5968. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that prosthetic accessories are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee requires an assistive device 
for mobility after an above the knee amputation. There is no indication he functions at a K3 level. The 
requested K3 knee and foot accessories are not reasonable or medically necessary based on the submitted 
documentation. 
 
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 upgraded components for a prosthesis described by codes L5981 and L5968.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital level of care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the inpatient level of care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the criteria for the inpatient level of care are not met. Our physician reviewer found the 
enrollee is experiencing pain in his left shoulder that is affecting activities of daily living. He is planned for a 
left shoulder surgery. He is medically stable. The approved procedure is approved at the outpatient level of 
care. There is no documentation to support that the enrollee will require a greater than two midnight stay for 
the procedure; therefore, inpatient care 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital level of care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 13, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of 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 June 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95941 billed for date of service June 27, 
2022. 
 
You asked the Plan to pay for procedure code 95941. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 95941 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 95941 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 95941 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 95941 billed for date of service June 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 heavy-duty power wheelchair (K0862), power 
seating system, combination tilt and recline (E1007), and electronic connection between wheelchair controller 
and 2 or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve a group 3 heavy-duty power wheelchair, power seating system, combination 
tilt and recline, and electronic connection. 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 power wheelchairs and accessories are covered when 
specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 3 heavy-duty power 
wheelchair, power seating system, combination tilt and recline, and electronic connection. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the documentation does not 
indicate that you are unable to use a manual wheelchair or a scooter for mobility. Furthermore, there is no clear 
indication that you would be able to use the requested power wheelchair in your home. 
 
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 group 3 heavy-duty power wheelchair, power seating system, combination tilt 
and recline, and electronic connection have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a group 3 heavy-duty power wheelchair (K0862), power seating system, combination tilt and 
recline (E1007), and electronic connection between wheelchair controller and 2 or more power seating system 
motors (E2311).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for spine surgery. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that you have tried other measures with no 
results. The Plan denied your request. The Plan says studies have not proven that this is helpful for treatment of 
the enrollee's health problems. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental when used as bone graft material. 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate for spine surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable drug delivery system and supplies (codes 
A4305 and A4223) provided from July 14, 2022, to July 18, 2022. 
 
You asked the Plan to pay for the disposable drug delivery system and supplies. You say that these items were 
needed for the delivery of the patient's medication. The Plan denied your request. The Plan says these items are 
not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including 
elastomeric infusion pumps (A4305, A4306, A9274) are non-covered devices because they do not meet the 
Medicare definition of durable medical equipment. Drugs and supplies used with disposable drug delivery systems are also non-covered items.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the disposable drug delivery system and supplies have not been met. Therefore, we decided that the 
Plan does not have to pay for the disposable drug delivery system and supplies (codes A4305 and A4223) 
provided from July 14, 2022, to July 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mobile imaging services provided on September 13, 
2022. 
 
You asked the Plan to pay for the billed services. You say that medical records support the services. The Plan 
denied your request. The Plan says the services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Swallow studies (74230 and 74240) with contrast were provided. We looked at the file and the rules. 
Procedures involving the use of contrast media is not covered under the portable x-ray provision. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for the mobile imaging services provided on September 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nonstandard seat frame, width greater than or equal to 
20 inches and less than 24 inches (E2201), solid seat support base (replaces sling seat), includes any type 
mounting hardware (E2231), backrest height adjustable 8-degree bend with push (K0108), pneumatic 
propulsion tires (E2211x2), insert for pneumatic propulsion tire (E2213x2). 
 
You asked the Plan to pre-approve manual wheelchair accessories. You say that the requested accessories are 
medically necessary for the enrollee. The Plan denied your request. The Plan says the requested accessories 
cannot be approved and are not medically necessary. Medicare criteria does not cover the requested items. 
 
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 manual wheelchair accessories. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested accessories exceed the enrollee's medical need as the 
approved wheelchair includes standard tires and solid seat insert. The nonstandard seat frame, width greater 
than or equal to 20 inches and less than 24 inches (E2201), is not medically necessary as the documentation 
does not support that the enrollee needs a nonstandard seat frame based on the measurements. The requested 
items do not meet medically necessary criteria per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 
411.15(k), 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of manual wheelchair accessories have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a nonstandard seat frame, width greater than or equal to 20 inches and 
less than 24 inches (E2201), solid seat support base (replaces sling seat), includes any type mounting hardware 
(E2231), backrest height adjustable 8-degree bend with push (K0108), pneumatic propulsion tires (E2211x2), 
insert for pneumatic propulsion tire (E2213x2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 38510 and 38900 provided on August 23, 2022.  
You asked the Plan to pay for codes 38510 and 38900. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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 CPT codes 38510 and 38900 are not supported in the medical record. Specifically, code 38510 
was billed with an inappropriate modifier. An anatomical modifier is required. Since primary procedure code 
38510 is not covered, this means code 38900 is an add-on code and has not been billed with an appropriate 
primary procedure code. Based on this information, we decided that Medicare rules for coverage of codes 
38510 and 38900 have not been met. Therefore, we decided that the Plan does not have to pay for codes 38510 
and 38900 provided on August 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of 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 August 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Posaconazole tablet 100mg DR. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered drug does not fall under Part B coverage. 
 
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 Posaconazole tablet 100mg 
DR.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing billed with code G0482 for 
September 6, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code G0482 is not supported. 
 
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 G0482 is definitive drug testing, 15-21 drug classes. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records show that only 
nine drug classes were tested. 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 the definitive drug 
testing billed with code G0482 for September 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 additional home health care skilled nursing visits. 
 You asked the Plan to pre-approve home health services. You say that you need more than 5 days of services 
for your wounds to heal. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee has wounds that are clean with little drainage and not on pressure bearing surfaces. The enrollee is 
monitored via a wound care center and at this point the wounds do not appear to be of the complexity to require 
additional home health nursing for wound care. The enrollee's caregivers have also been educated in terms of 
providing wound care. The enrollee can continue receiving the 5 visits that were approved and does not require 
an additional 5 visits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 5 additional home health care skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service July 23, 
2022. 
 You asked the Plan to pay for procedure code 99053. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99053 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service July 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endosteal implant (D6010) provided on September 30, 
2022. 
 
You asked the Plan to pay for an endosteal implant. You say that you would like the Plan to pay for this. The 
Plan denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
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 pay for an 
endosteal implant (D6010) provided on September 30, 2022.