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 (PWC) with multiple 
power options, including power tilt and recline seating systems. 
 
You asked the Plan to pre-approve the Group 3 PWC with multiple power options. You say that it is felt that 
the requested type of PWC is needed to address the enrollee's mobility deficits. The Plan denied your request. 
The Plan says the enrollee does not meet the criteria for the requested base PWC code with multiple power 
options. 
 
The Plan follows Medicare rules. Medicare rules say that Group 3 PWCs with multiple power options are 
covered when the enrollee meets the coverage criteria for a power tilt and recline seating system as defined in 
the Medicare rules section of this decision.  
 
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 Group 3 PWC with multiple power options. Our reviewer says that the PWC with multiple power options is not considered reasonable and 
necessary based on LCD criteria. Our physician reviewer found the provided records do not document that the 
enrollee is high risk for skin breakdown, has a history of pressure ulcer(s) or has had skin flap surgery. Records 
do not document the enrollee performs bladder self-catheterization and is unable to transfer independently or 
that the enrollee has increased lower extremity muscle tone or spasticity to qualify for the multiple power 
options, power tilt and recline. As the power wheelchair base with multiple power options does not meet 
criteria for coverage, the requested accessories (expandable controller and related hardware and the seat 
cushion and positioning back cushion) are not covered.  
 
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 Group 3 PWC with multiple power options have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple power 
options, including power tilt and recline seating systems.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on January 19, 2022. 
 
You asked the Plan to pay for acupuncture. You say that you are able to provide these types of services. The 
Plan denied your request. The Plan says acupuncture is only covered for chronic low back pain and records 
provided show it was to treat left hip pain. 
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, acupuncture is only covered for chronic low back 
pain and the acupuncture was done to treat left hip pain. Therefore, we decided that the Plan does not have to 
pay for acupuncture services provided on January 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious disease testing (0242U) provided on December 8, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for out-of-network lab services. You say that these services were ordered by a 
network provider. The Plan denied your request. The Plan says out-of-network care is covered only in certain 
limited circumstances. The services at issue were not urgent or emergent, nor were they pre-approved or 
referred by a contracted provider. 
 
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 infectious disease testing (0242U) provided on 
December 8, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 22, 2022, and  
February 23, 2022. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. The Plan says non-emergent, non-
urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on February 22, 2022, and 
February 23, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99283 billed for date of service April 4, 
2022. 
 
You asked the Plan to pay for procedure code 99283. You say that this service was performed. The Plan denied 
your request. The Plan says payment for code 99283 is bundled into payment for code 99284. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99283 
is a column II code to column I code 99284. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99283 billed for date of service April 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 2, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for out-of-network lab services. You say that these services were necessary and 
should be covered. The Plan denied your request. The Plan says out-of-network services are only covered in 
certain limited circumstances. The requested lab services were not urgent or emergent, they were not pre-
approved, and they were not referred by a contracted provider. 
 
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 lab services provided on November 2, 2021, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new terminal device for a right trans-radial 
myoelectric prothesis. 
 
You asked the Plan to pre-approve the new terminal device. You say that the current prosthesis has required 
multiple repairs due to the patient's limited vision which has caused damage to the device. The requested 
device would be much more durable for the patient to utilize. The Plan denied your request. The Plan says the 
requested prostheses is not reasonable and necessary, as the current prosthesis is under warranty. 
 
The Plan follows Medicare rules. Medicare rules say that replacement may be covered for an artificial limb 
when certain coverage criteria are met as described in the Medicare rules section of this decision.  
 
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 new terminal device. Our reviewer 
says that the requested device is not shown to be reasonable and necessary. Our physician reviewer found the 
documentation does not reveal that the patient is unable to use his current terminal limb device for his activities of daily living. The documentation indicates that the patient is still attending occupational therapy (OT). There 
are no objective OT notes or physician documentation supporting the need for this terminal device for activities 
of daily living. There is no objective treating medical provider documentation indicating vision impairment. 
The documentation reveals that the current device is still under warranty.  
 
The criteria for replacement have not been met. There is no evidence that the current device has had an 
irreplaceable change of condition or requires repairs that are over 60 percent of the cost of a replacement. There 
are no objective therapy notes indicating that the patient is unable to complete current activities without the 
requested device or that the patient requires the Forced Limiting Auto Grasp (FLAG) options of the requested 
device. 
 
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 new terminal device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a new terminal device for a right trans-radial myoelectric prothesis.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0427, A0425) provided on January 15, 
2022. 
 
You asked the Plan to pay for ambulance services. You say that these services were provided due to a fall. The 
Plan denied your request. The Plan says the Plan is not responsible for payment of services when the enrollee is 
enrolled in hospice. 
 
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 ambulance services (A0427, A0425) provided on January 15, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis provided on April 4, 2022. 
 
You asked the Plan to pay for the knee orthosis. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the record is missing required documentation. 
 
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 a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the documentation did not include a valid proof of delivery or a delivery ticket to indicate the 
specific supplies rendered. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the knee orthosis 
provided on April 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care provided to the enrollee on August 9, 
2021. 
 
You asked the Plan to pay for the services. You say that the claim was originally submitted as primary payer, 
which was within timeframe. The Plan denied your request. The Plan says traditional Medicare pays for 
hospice services. 
 
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 initial hospital care provided to the enrollee on August 9, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) provided on February 21, 
2022. 
 
  You asked the Plan to pay for moderate sedation services (99153). You say that the attached medical records 
support the services rendered and the claim should be reconsidered for payment. The Plan denied your request. 
The Plan says CPT code 99153 may not be paid if furnished to a hospital inpatients or patients in a hospital 
outpatient department. 
 
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 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a TC 
only code and the claim indicates that this service was rendered in a facility setting. Payment for CPT code 
99153 is made to the facility and is the responsibility of the facility to any physician or vendor. Based on this 
information, we decided that Medicare rules for coverage of moderate sedation services (99153) have not been 
met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) provided 
on February 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on March 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for podiatry services. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 podiatry services provided on March 25, 2022, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second abdomen chest x-ray provided to the enrollee on 
January 6, 2022. 
 
You asked the Plan to pay for the x-ray. You say that this should be paid for. The Plan denied your request. The 
Plan says the records submitted do not indicate that two separate services were performed. 
 
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 74018 is "Radiologic examination, abdomen; 1 view." 
 
We asked our coder 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 x-ray. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that the provider states that a second exam 
was done on the same date. However, the records provided only a single abdominal film was done on this date. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have 
to pay for a second abdomen chest x-ray provided to the enrollee on January 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Somatuline Depot. 
 
You asked the Plan to pre-approve Somatuline Depot. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Somatuline Depot. Our reviewer says 
that the requested drug is not medically necessary or reasonable. Our physician reviewer found the enrollee has 
a fistula of the stomach and duodenum (gastrocutaneous fistula) after a duodenostomy tube secondary to a 
perforated duodenal ulcer. Somatuline Depot is not Food and Drug Administration (FDA) approved for 
treatment of fistula of the stomach and duodenum. Treatment of fistula of the stomach and duodenum with 
Somatuline Depot is not supported by one of the major drug compendia or by clinical research that appears in a 
CMS-approved medical journal. Therefore, the enrollee does not meet criteria for the requested drug. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Somatuline Depot have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Somatuline Depot.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve additional trips. You say that you need additional transportation. The Plan 
denied your request. The Plan says the Evidence of Coverage clearly states 100 one-way trips per calendar year 
the 101st and beyond is not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of [ENTER PLAN MAXIMUM # OF TRIPS] trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) of the heart with quantitative 
evaluation of coronary calcium for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the request cannot be approved because it is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found that the enrollee cannot be 
classified as asymptomatic, as he has intermittent chest pain, sinus tachycardia, and some abnormality of the 
ST segment on electrocardiogram. Thus, he qualifies for coronary calcium scoring. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
computed tomography (CT) of the heart with quantitative evaluation of coronary calcium for the enrollee.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home modifications (S5165), specifically a medical 
sauna and cold plunge. 
 
You asked the Plan to pre-approve the home modifications. You say that since using a medical sauna and cold 
plunge, you have prevented emergency room visits and decreased the number of intensive care unit (ICU) and 
hospital stays. You also say that these items have allowed you to manage your symptoms and be more 
independent at home. The Plan denied your request. The Plan says the requested home modifications are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary].  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home modifications have not been met. Specifically, there is no indicate that you cannot 
performed your Activities of Daily Living (ADLs) in your home without the requested equipment. Therefore, 
we decided that the Plan does not have to pre-approve home modifications (S5165), specifically a medical 
sauna and cold plunge.