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

 
We decided that the Plan does not have to pre-approve all lower extremity prosthesis, shank foot system with 
vertical loading pylon (CPT code L5987) and all endoskeletal lower extremity prosthesis, axial rotation unit, 
with or without adjustability (CPT code L5984). 
 
You asked the Plan to pre-approve the items. You say that the items are medically necessary. The Plan denied 
your request. The Plan says L5984 does not represent a complete foot. The Plan states it is part of a foot that 
must be paired with a complete foot based on your functional classification. The Plan states the vendor 
indicates that your "expected beneficiary functional level" is K3, which, as noted above, is not supported by the 
medical record. If this part is needed, this need must be corroborated by provider without financial interest in 
the claim outcome, as noted. The Plan states there must be clear documentation why this part is needed, which 
has not been provided. 
 
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 items. Our physician reviewer 
found the documentation does not indicate you are a K3 level ambulator. The requested part of the prosthetic 
foot is not medically necessary as it would be paired with a complete foot based on a K3 level prosthesis. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve all lower extremity prosthesis, shank foot system with vertical loading pylon (CPT code L5987) 
and all endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability (CPT code L5984).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a lumbar-sacral orthosis provided on 
December 29, 2020. 
 
You asked the Plan to waive the coinsurance for a lumbar-sacral orthosis. You say that the original cost of the 
supportive belt should not cost over $500. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment that is $500 or more. 
 
You have been asked to pay $177.45, which is 20% coinsurance of the allowed amount for a lumbar-sacral 
orthosis ($887.24 allowed amount x 20% coinsurance = $177.45). A lumbar-sacral orthosis falls within the Durable Medical Equipment (DME) and Related Supplies 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 coinsurance for a lumbar-sacral orthosis provided on December 29, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network for skilled nursing facility services. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are network facilities available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network for skilled nursing facility services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 11, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service January 11, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on July 12, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the drug testing services provided on July 12, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you are unable to go home and care for yourself. 
The Plan denied your request. The Plan says that the services you require including intermittent therapy, can 
safely be received at a different setting. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) visit (99283) provided on 
March 22, 2021. 
 
You asked the Plan to pay for the ED visit. The Plan denied your request. The Plan says Medicare will pay for 
dental services that are an integral part either of a covered procedure or for extractions done in preparation for 
radiation treatment for neoplastic diseases under Part B when performed by a physician. The Plan also says that 
the appealed services do not fall under the covered services. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that are 
not covered or paid for by Medicare. The record shows that the enrollee presented to the ED due to a toothache. 
The documentation states the enrollee had an appointment scheduled in May but could not wait until then. Therefore, we decided that the Plan does not have to pay for the emergency department (ED) visit (99283) 
provided on March 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crutch substitute (CPT code E0118). 
 
You asked the Plan to pre-approve the crutch substitute. You say that it is imperative that the enrollee be non-
ambulatory on their left foot due to a non-healing ulcer. The Plan denied your request. The Plan says Medicare 
says that a crutch substitute, such as a knee walker, has not been proven to be safe and effective. 
 
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 crutch substitute. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is to be non-weight bearing to the lower extremity. The knee scooter 
(knee walker) has not been shown to be safe and effective over crutches; therefore, it 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 the crutch substitute have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the crutch substitute (CPT code E0118).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tub stool or bench. 
 
You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
We looked at the file and the rules. While a shower chair may be appropriate in this case, neither the Plan nor 
Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a tub 
stool or bench.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ajvoy. 
 
You asked the Plan to pre-approve Ajvoy. The Plan denied your request. The Plan says for coverage under Part 
B, this medication must be furnished by the physician. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Ajvoy.  
 
Benefits for Ajvoy may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health physical therapist (PT) visits (CPT 
code G0151 X 6). 
 
You asked the Plan to pre-approve the home health physical therapist visits. You say that the services are 
medically necessary. The Plan denied your request. The Plan says the approved physical therapy visit(s) should 
be enough for the enrollee's provider to start their care and complete assessment. 
 
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 home health physical therapist 
visits. Our physician reviewer found the documentation does not support that the enrollee requires additional 
skilled nursing services to provide treatment that is medically necessary. The enrollee does not require 
additional skilled rehabilitation services to effectively provide treatment, care, and/or services in order to 
improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or 
prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic 
medical problems or hospitalizations. The requested home health services 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 the home health physical therapist visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the home health physical therapist (PT) visits (CPT code 
G0151 X 6).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental items. You say that you need these services. The Plan denied your 
request. The Plan says partial dentures are covered once in a 60 month period. The Plan also says the frequency 
limit has been reached. 
 
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 and partial dentures are listed as 
covered, the frequency limit has been reached. The record shows that the Plan paid for a partial upper denture 
and a partial lower denture that you received on August 26, 2019. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on 
September 9, 2021. 
 
You asked the Plan to pay for the special anesthesia service (99100). You say that the services were rendered 
based on the patient condition. You say that the services were essential to their quality of health and coded 
appropriately. The Plan denied your request. The Plan says procedure code 01480 has been overturned. The 
Plan also says that CPT code 99100 remains denied as bundled services are not eligible for separate payment.  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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on September 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve multiple dental implants (D6010). 
 
You asked the Plan to pre-approve dental implants. You say that these services are necessary. The Plan denied 
your request. The Plan says these services are not covered by your dental benefit. 
 
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 pre-approve 
multiple dental implants (D6010).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's goal is to return to her prior level of 
function. The Plan denied your request. The Plan says the enrollee does not require close physician oversight or 
use of specialized equipment or therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found 
that the enrollee was admitted to the acute care hospital for a left acetabular fracture after a fall. She was 
transferred to skilled nursing. Her medical problems are stable.  The enrollee does not require treatment by multiple therapies in an intensive rehabilitation therapy program. 
While she has a need for physical and/or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sterile gloves (A4930) provided on December 16, 2021. 
 
You asked the Plan to pay for sterile gloves. You say that you would like this claim reprocessed based on the 
medical documentation. The Plan denied your request. The Plan says payment cannot be made for this item as 
the Medicare Unlikely Edit is 0. 
 
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 A4930 is gloves, sterile, per pair. 
 
We find that CPT code A4930 is not supported in the medical record. Specifically, the documentation does not 
reference the necessity of this item. Furthermore, this claim also has a Payment Status Indicator of N indicating 
that it is packaged into other services an no separate payment is made. Based on this information, we decided 
that Medicare rules for coverage of sterile gloves have not been met. Therefore, we decided that the Plan does 
not have to pay for sterile gloves (A4930) provided on December 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on January 9, 
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 an appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. 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 imaging services provided to the enrollee on January 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a deluxe canopy with side windows (K0108) and a 
transit option (K0108). 
You asked the Plan to pre-approve a deluxe canopy with side windows and a transit option. You say that you 
would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a deluxe canopy 
with side windows and a transit option are not to be used within the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The items at issue in this appeal are for use outside of the home. Although these items may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a deluxe canopy with side windows (K0108) and a transit option (K0108).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the blood vessels of the 
chest. 
 
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 this is not medically necessary. 
 
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 there was a negative chest 
x-ray on 1/18/22. In a patient with pleuritic chest pain and shortness of breath, the diagnosis of exclusion is 
pulmonary embolism and the most appropriate test to exclude this diagnosis is a CT pulmonary angiogram. 
Even if a more recent chest x-ray had been done, a negative exam would not preclude the need or indication for 
the ordered scan. 
 
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 
a computed tomography (CT) scan of the blood vessels of the chest.  
 
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.