Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four physical therapy (PT) visits (G0151 x4) and five 
occupational therapy (OT) visits (G0152 x5). 
 
You asked the Plan to pre-approve the PT and OT visits. You say that you believe these services are necessary 
and urgently needed. The Plan denied your request. The Plan says the request for 4 additional PT visits does 
not meet medical necessity criteria. The Plan also says the clinical documentation does not show that ongoing 
skilled OT services are needed to provide services to restore function or to prevent deterioration. 
 
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 the PT and OT visits. Our reviewer says 
that the PT and OT visits are not reasonable and necessary. Our physician reviewer found you do not have 
documented skilled therapy needs. Our reviewer also found that you appear to be functioning at your baseline 
and have the necessary durable medical equipment. 
 
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 PT and OT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve four physical therapy (PT) visits (G0151 x4) and five occupational therapy (OT) 
visits (G0152 x5).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance transportation provided on 
January 28, 2022. 
 
You asked the Plan to waive the copayments for ambulance transportation. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says the cost share has been 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 $300 
copayment per one-way trip by ground or air ambulance.  
 
You have been asked to pay $482.69 for ambulance transportation. Ambulance transportation falls within the 
Ambulance Services benefit category. Please note: two separate ambulance services were provided. Your 
contract with the Plan clearly says that you must pay $300 per one-way trip by ground or air ambulance.  For one ambulance trip, you have been asked to pay a $300 copayment. For the other ambulance trip, you have 
been asked to pay the allowed amount of $182.69. This results in your total copayment responsibility of 
$482.69. 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 for ambulance transportation provided on January 
28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided May 4, 2022. 
 
You asked the Plan to pay for the limited oral exam. You say that your dentist should have checked what type 
of evaluations are covered. The Plan denied your request. The Plan says this service is not covered under your 
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 pay for the 
limited oral evaluation - problem focused (D0140) provided May 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36222 and 36225 billed for date of service 
April 4, 2022. 
 
You asked the Plan to pay for procedure codes 36222 and 36225. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for code 36222 is bundled into payment for code 
36223. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a 
distinct procedural service. Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 36222 is a column II code to column I code 36223. We have 
confirmed that code 36225 is a column II code to column I code 36226. While these codes were billed with the 
-59 modifier, the medical records provided do not show that the services billed with the -59 modifier are a 
distinct procedural service. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 36222 and 36225 billed for date 
of service April 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a resin-based composite tooth #16 (D2391), core 
buildup for tooth #09 and 11 (D2950), a resin-based composite for tooth #6 (D2331), a crown - porcelain/ceramic for tooth #09 and 11 (D2740), a maxillary partial denture (D5213), and a mandibular partial 
denture (D5214). 
 
You asked the Plan to pay for the dental services. You say that you received a written document prior to any 
dental work containing what the Plan will cover and the remaining would be your responsibility. The Plan 
denied your request. The Plan says your claims have been processed correctly.  
 
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, certain limitations apply. The record 
shows your benefits for the resin-based composite tooth #16 (D2391) and core buildup for tooth #09 (D2950) 
were exhausted on date of service May 25, 2022. Therefore, the Plan does not have to pay for these two 
services. 
 
Additionally, you have been asked to pay the following cost sharing amounts for the approved services. 
 
Dental Code Tooth # Allowed Amount Coinsurance Deductible 
D2331 6 $93  $50 
D2740 9 $584 $292 (50%)  
D2740 11 $584 $292 (50%)  
D2950 11 $101 $50.50 (50%)  
D5213  $765 $192.25 (25%)  
D5214  $765 $192.25 (25%)  
 
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 pay more for a resin-based composite tooth #16 (D2391), 
core buildup for tooth #09 and 11 (D2950), a resin-based composite for tooth #6 (D2331), a crown - 
porcelain/ceramic for tooth #09 and 11 (D2740), a maxillary partial denture (D5213), and a mandibular partial 
denture (D5214).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve. 
 
You asked the Plan to pre-approve intraosseous ablation of the basivertebral nerve. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 intraosseous ablation of the 
basivertebral nerve. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found at this point in time, this is considered an 
experimental/investigational procedure. Therefore, 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 intraosseous ablation of the basivertebral nerve have not been met. Therefore, 
we decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0037U) provided on April 12, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the records do not support the billed services. 
 
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 code 0037U is not supported in the medical record. Specifically, the date of service billed 
does not match the date the specimen was collected per the records (February 16, 2022). Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for genetic testing (0037U) provided on April 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE) procedure. 
 
You asked the Plan to pre-approve a TTE procedure. 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 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 TTE procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation would not point to a change in status that would support the medical 
necessity of a repeat TTE at this time. Clinical guidelines do not support repeating a TTE following a relatively 
recent TTE, with no intervening change in clinical status or new signs, symptoms or physical findings. In 
summary, there is no supportive evidence for the medical necessity of repeat TTE in this enrollees clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a TTE procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a transthoracic echocardiogram (TTE) procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF System. 
 
You asked the Plan to pre-approve a CardioMEMS HF System. 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 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 CardioMEMS HF System. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there remains a dearth of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this 
time the CardioMEMS system would not be considered medically appropriate and necessary in this enrollees 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CardioMEMS HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF System.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal fusion of the sacrum. 
 
You asked the Plan to pre-approve spinal fusion of the sacrum. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 spinal fusion of the sacrum. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documented sacroiliac (SI) joint instability, fracture, or lesion. 
SI joint fusion for degenerative back pain is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal fusion of the sacrum have not been met. Therefore, we decided that the 
Plan does not have to pre-approve spinal fusion of the sacrum.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry services provided on April 18, 
2022. 
 
You asked the Plan to waive the copayment for podiatry services. You say that you were told that toenail trims 
were going to be paid unless you go something else. The Plan denied your request. The Plan says this cost 
sharing was charged 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 $45 
copayment for podiatry services. 
 
You have been asked to pay a $45 copayment for podiatry services. This item/service falls within the podiatry 
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 podiatry services provided 
on April 18, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for non-emergency ground transportation and mileage (A0425, A04258) 
provided on March 8, 2021. 
 
You asked the Plan to pay for non-emergency ground transportation and mileage (A0425, A04258). You say 
that you received a letter dated May 24, 2021, requesting trip notes on June 16, 2021. You also say that the 
information was faxed to the provided number and a fax confirmation was received. The Plan denied your 
request. The Plan says that the requested information was not received within 45 days from the date on the 
letter to process the claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan denied the appeal stating that the trip report was not received within 45 
days from the date on their requested letter. However, there is no Medicare rule stating that a trip report has to 
be submitted within 45 days. The Evidence of Coverage also does not mention any rules that a trip report has to 
be submitted within 45 days. The record shows that the provider submitted the required documentation to 
support coverage. The record also shows that the Plan has not shown that they have any legitimate basis to 
continue denying this service. Therefore, we decided that the Plan has to pay for non-emergency ground 
transportation and mileage (A0425, A04258) provided on March 8, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the elbow orthosis equipment (L3761) provided on May 3, 
2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says the documentation 
submitted did not sufficiently support the billed supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. In this case, the documentation does not support that the ordering provider discussed the medical 
necessity of the ordered equipment with the enrollee. Therefore, we decided that the Plan does not have to pay 
for the elbow orthosis equipment (L3761) provided on May 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve the MyoPro Motion G orthosis. You say that this device is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says this device 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 MyoPro Motion G orthosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the MyoPro is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 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 MyoPro Motion G orthosis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the MyoPro Motion G orthosis.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the services are necessary. The 
Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an epidural steroid injection. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the request meets the criteria and is medically reasonable and 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 an epidural steroid injection have been met. Therefore, we decided that the Plan 
has to pre-approve an epidural steroid injection.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the EKG provided on June 07, 2022. 
 
You asked the Plan to reduce the copayment for the EKG. You say that you paid less for the same service last 
year. The Plan denied your request. The Plan says this cost sharing was charged 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 
$138.93 copayment for non-radiological diagnostic procedures and tests. 
 
You have been asked to pay a $138.93 copayment for the EKG. This item/service falls within the non-
radiological diagnostic procedures and tests 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. The total allowed amount for the EKG and office visit is $138.93. Since this 
amount is less than the $175 copayment per the EOC, you are only responsible for the lesser amount. 
Therefore, we decided that the Plan does not have to reduce the copayment for the EKG provided on June 07, 
2022.