Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve service dog special supplemental benefits for the 
chronically ill. 
 
You asked the Plan to pre-approve service dog benefits. You say that the enrollee qualifies for the service dog 
benefit. The Plan denied your request. The Plan says the criteria required for coverage is missing. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition. The Plans contract specifies one of these benefits is a service dog 
benefit. You must provide supporting documentation identifying you as the owner and recipient of a service 
dog trained as described under the Americans with Disabilities Act. 
 
We looked at the file and Medicare rules. In this case, no documentation has been provided that indicate the 
service dog in question is a trained service dog as described under the Americans with Disabilities Act. Based 
on this information, we decided that Medicare rules for coverage of service dog benefits have not been met. Specifically, we have confirmed that you do not have one of the eligible conditions listed in the Evidence of 
Coverage. Therefore, we decided that the Plan does not have to pre-approve service dog special supplemental 
benefits for the chronically ill.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that your husband has fallen several 
times from the bed, by removing the railing. You need a full electric bed because you cannot control him. You 
also say that the enrollee has Parkinsons disease and on August 26, 2022, had a surgery for a placement of 
feeding tube. You need the bed urgently. The Plan denied your request. The Plan says coverage is not provided 
for a fully electric hospital beds because the height adjustment feature is a convenience feature and is not 
reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on April 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for podiatry services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 April 21, 2022, 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 group 3 power wheelchair (PWC) with multiple power 
features (K0861), a power seat elevation feature (E2300), and an expandable controller (E2377, E2313, 
E2311). 
 
You asked the Plan to pre-approve the group 3 power wheelchair with multiple power features and accessories. 
You say that the requested wheelchair and features are medically necessary. The Plan denied your request. The 
Plan says a standard group 3 power wheelchair without power options can be considered. The requested 
features exceed the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with related power 
features and accessories is covered when medically necessary. Power seat elevation features are non-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 group 3 power wheelchair with 
multiple power features and accessories. Our reviewer says that the requested group 3 power wheelchair with 
multiple power options is not medically necessary. Our physician reviewer found the enrollee is capable of 
weight shifting and does not use a ventilator or intermittent catheterization. She does not require a single switch 
to manage multiple power drive systems. The power seat elevation is non-covered per Medicare rules. 
 
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 power wheelchair with multiple power features and accessories 
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 features (K0861), a power seat elevation feature (E2300), and an 
expandable controller (E2377, E2313, E2311).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care assistance services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that in this case, 
the documentation doesnt support that you require skilled nursing services or skilled rehab services to provide 
treatment that is medically necessary. You do not require personal care assistance services to effectively 
provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to 
maintain your condition and/or prevent deterioration. There is no documentation to support 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve personal care assistance services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the lower extremity 
(73700). 
 
You asked the Plan to pre-approve a CT of the lower extremity. You say that you need to have a less invasive 
surgery. The Plan denied your request. The Plan says a CT scan performed solely to plan for robot assisted 
surgery 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 a CT of the lower extremity. Our 
reviewer says that a CT of the lower extremity is not reasonable and necessary. Our physician reviewer found 
the Plan has determined that the medical literature does not support the routine use of computer-assisted 
navigated total knee arthroplasty over conventional total knee arthroplasty. This is due to the lack of large 
volume long term studies evidencing significantly different outcomes regarding pain and function with 
robot/navigated arthroplasty. Our reviewer also found that as the proposed Mako robotic arm surgery has not 
been approved, the CT scan is not considered medically reasonable and necessary for you in this case. 
 
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 CT of the lower extremity have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a computed tomography (CT) of the lower extremity (73700).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 11, 2022 billed with 
codes 81272, 81206, 81210, and 81235. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 11, 2022 billed with codes 81272, 81206, 81210, and 81235.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from the highest level of 
rehabilitation to regain her maximum function. The Plan denied your request. The Plan says that while the 
member will likely benefit from ongoing therapy to enhance rehabilitation potential, there is no evidence that 
this cannot safely be done at a lower level of care. 
 
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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the members nursing, medical and rehabilitation needs do not require an acute rehab hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not require treatment 
by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation 
therapy program. The member can receive further services at a lower level of care. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service March 8, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 83789 is bundled into payment for code G0481. 
 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 83789 
is a column II code to column I code G0481. 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 83789 billed for date of service March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits coded 99215 provided on July 13, 2021 and 
July 19, 2021. 
 
You asked the Plan to pay for the office visits. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 99215 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is 
spent on the date of the encounter. 
 
We find that CPT code 99215 is not supported in the medical record. Specifically, the documentation submitted 
appear to be therapy notes instead of evaluation and management services. In addition, the documentation 
submitted it partially illegible. This means this service is not supported by the documentation. Based on this 
information, we decided that Medicare rules for coverage of the office visits have not been met.  Therefore, we decided that the Plan does not have to pay for the office visits coded 99215 provided on July 13, 
2021 and July 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on April 21, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you had this procedure done 
before and the device came out resulting in a second procedure so it should be covered. The Plan denied your 
request. The Plan says the copayment applied is correct. 
 
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 $375 
copayment per visit.  
 
You have been asked to pay $375 copayment for outpatient surgery. Outpatient surgery falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 outpatient surgery provided 
on April 21, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the LUCI model 101 system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the requested system does not have Food and Drug Administration (FDA) approval 
and is considered experimental and investigational. 
 
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 the system. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that Amyotrophic Lateral Sclerosis (ALS) is a neurodegenerative disease and based on current 
documentation you need an eye gaze system to operate the current power wheelchair inside the home. Thus, the 
requested system is 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 system have been met. Therefore, we decided that the Plan has to pre-
approve the LUCI model 101 system.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure. 
 
You asked the Plan to pre-approve the Minuteman procedure. You say that this procedure is medically 
reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the 
requested procedure 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 Minuteman procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee is a 66-year-old male being treated for spondylolisthesis of 
the thoracolumbar region. He presented with pain in the bilateral lower back down the bilateral legs to the feet. 
He was last seen on March 18, 2022, for a transforaminal epidural steroid injection at L4-5, bilaterally. He had 
initial 50% benefit with short-term relief. The pain is aching, dull, and itching. The pain is 7/10 on average. 
The exam reveals moderate pain on all range of motion with limited range of motion. There is tenderness noted 
in the bilateral sciatic notch, vertebral spine, and sacroiliac joint. Straight leg raise is positive bilaterally. 
Strength is 5/5.  
In this case, current evidence based medical guideline and peer-reviewed literature do not fully support the 
interspinous fusion device procedure that is requested over the gold standard of lumbar fusion. There is a lack 
of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees 
medical condition. 
 
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 Minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Minuteman procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of head or brain (70450), 
and a computed tomography (CT) scan of cervical spine (72125) provided on April 26, 2022. 
 
You asked the Plan to pay for a CT scan of head or brain, and a CT scan of cervical spine. You say that the 
enrollee had multiple imaging studies done on the same day. The Plan denied your request. The Plan says this 
claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
   
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 31, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for a CT scan of head or brain, and a CT scan of 
cervical spine have not been met. Therefore, we decided that the Plan does not have to pay for a computed 
tomography (CT) scan of head or brain (70450), and a computed tomography (CT) scan of cervical spine 
(72125) provided on April 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 27, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that due to the patient misleading the office of incorrect 
insurance, the office was unable to obtain authorization. The Plan denied your request. The Plan says the 
provider is out-of-network and authorization is required prior to an out-of-network visit. 
 
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 an office visit provided on December 27, 2021, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided on January 21, 2022. 
 
You asked the Plan to pay for the services provided. You say that the documentation supports the level of care 
billed. The Plan denied your request. The Plan says the billed code remains 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in 
the medical record. Specifically, the records do not document the total time critical care services were 
furnished. Based on this information, we decided that Medicare rules for coverage of the services provided 
have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services 
provided on January 21, 2022.