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

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness for an upgrade to an expandable controller 
(E2313), an expandable controller (E2377), a backrest cloth cover and an avid velocity black shroud (K0108). 
 
You asked the Plan to pre-approve power wheelchair accessories. You say that the enrollee has pressure 
wounds and is in immediate need of this equipment. The Plan denied your request. The Plan says although 
there are 3 requested power options, there is not a medical need to control these power options through the 
joystick. The Plan also says the backrest cloth cover and the black shroud do not serve a medical purpose and 
therefore not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller and 
two or more power seating system motors (E2311), a harness for an upgrade to an expandable controller 
(E2313), an expandable controller (E2377), a backrest cloth cover and an avid velocity black shroud (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that your leg was affected by Polio at age 2, and 
with this foot issue you should qualify for coverage. The Plan denied your request. The Plan says this item is 
not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of 
the brain (70553) provided on February 16, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $325 per 
day for other Medicare covered diagnostic radiology services that are not ultrasounds.  
 
You have been asked to pay $325 for the Medicare covered diagnostic radiology service provided. 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 the magnetic resonance imaging 
(MRI) of the brain (70553) provided on February 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81225, 81230, and 81291 
provided on November 15, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
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. 
 We find that CPT codes 81225, 81230, and 81291 are not supported in the medical record. Specifically, when a 
laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part 
of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. 
A panel constitutes one single procedural code, so one code must be submitted for the panel. Review of the file 
does not support that only one code has been billed for the panel provided. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services coded 81225, 81230, and 81291 provided on 
November 15, 2021.
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 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. 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. Our 
physician reviewer found the complexity of your nursing medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
provided in an inpatient rehabilitation facility. Therefore, the requested acute inpatient rehabilitation is 
considered 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 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 pre-approve the seat elevator (CPT code E2300). 
 
You asked the Plan to pre-approve the seat elevator. You say that the inclusion of the seat elevator would make 
it safer to be able to reach things and perform things independently. The Plan denied your request. The Plan 
says the seat elevator does not serve a medical purpose and is statutorily non-covered 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the seat elevator (CPT code E2300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
October 24, 2021, through October 28, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 $395 
copayment each day, for days 1 to 4 for Medicare-covered hospital care. Additionally, you must pay a $0 
copayment for additional Medicare-covered days.   
 
You have been asked to pay $1,580 ($395 copayment x 4 days) for the inpatient hospital care provided. 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 the inpatient hospital care 
provided from October 24, 2021, through October 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transperineal placement of a Perirectal Hydrogel Spacer 
(SpaceOAR Hydrogel System). 
 
You asked the Plan to pre-approve transperineal placement of a Perirectal Hydrogel Spacer (SpaceOAR 
Hydrogel System). You say that the requested transperineal placement of a Perirectal Hydrogel Spacer 
(SpaceOAR Hydrogel System) is medically necessary. The Plan denied your request. The Plan says the 
requested transperineal placement of a Perirectal Hydrogel Spacer (SpaceOAR Hydrogel System) is not 
medically necessary. 
 
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 transperineal placement of a Perirectal 
Hydrogel Spacer (SpaceOAR Hydrogel System). Our reviewer says that the requested transperineal placement 
of a Perirectal Hydrogel Spacer (SpaceOAR Hydrogel System) is not medically necessary. Our physician 
reviewer found SpaceOAR is a hydrogel spacer inserted between the rectum and prostate in order to reduce the 
dose exposure of the rectum- and thus rectal toxicity  in men undergoing radiation for prostate cancer. The 
hydrogel spacer can be considered medically necessary when justified. It would be within accepted standards 
of care to do so. 
 
However, the LCD criteria are not met, as the criteria are explicit in which risks groups are covered and also 
the need to use SpaceOAR when other techniques would be insufficient. This enrollee is being offered 
Stereotactic body radiotherapy (SBRT), and there is no specific reason as to why this alone (i.e. without 
SpaceOAR) would be insufficient in this specific enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transperineal placement of a Perirectal Hydrogel Spacer (SpaceOAR Hydrogel 
System) have not been met. Therefore, we decided that the Plan does not have to pre-approve transperineal 
placement of a Perirectal Hydrogel Spacer (SpaceOAR Hydrogel System).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve Endosteal dental implants, Zygomatic implant, Reconstruction of 
maxilla or mandible with endosteal implants, Removal of implant mesh, and Repair procedures on vestibule of 
mouth (D6010, D7994, 21249, 20660, and 40845). 
 
You asked the Plan to pre-approve the surgical services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says that the services are not covered by Medicare or your plan. 
 
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 surgical services. Our reviewer says 
that the services are medically necessary. Our physician reviewer found the reason for the denial was that the 
services are dental in nature. A review of the documentation indicates that these procedures are necessary due 
to a medical condition (osteomyelitis) which required bone grafts and antibiotics resulting in a deficiency of the 
alveolar bone. This deficiency required these reparative and restorative procedures to provide the enrollee with 
functional prostheses for adequate masticatory function. These procedures were the result of a medical 
condition and are 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 the surgical services have been met. Therefore, we decided that the Plan has to 
pre-approve Endosteal dental implants, Zygomatic implant, Reconstruction of maxilla or mandible with 
endosteal implants, Removal of implant mesh, and Repair procedures on vestibule of mouth (D6010, D7994, 
21249, 20660, and 40845).  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services. 
 
You asked the Plan to pay for the paramedic intercept services. You say that this is possible fraud because this 
was not the ambulance service you had. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the medical records 
provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollees medical conditions do not appear to require acute hospital level care and she is on outpatient medications with no issues 
that appear to require a physicians evaluation three or more times per week. The enrollee does require physical 
therapy and occupational therapy services, but the medical records provided do not clarify why the enrollee 
requires an intensive inpatient rehabilitation therapy program. Provided records do not explain why the 
intensive inpatient rehabilitation therapy program is necessary and why therapy at a lower level of care such as 
in a skilled nursing facility is not appropriate for the enrollee. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services. 
 
You asked the Plan to pre-approve dental services. You say that you are in pain. The Plan denied your request. 
The Plan says the services are not covered. 
 
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. 
 
The file shows that dental codes D7953, D9230, D9248, and D9610 were requested. Although the Plan offers a 
dental benefit in excess of Medicare coverage, the requested services are not among those covered under this 
benefit.  
 The file also shows that dental codes D6010 x4, D6057 x4, D6058 x4, and D6104 x4 were requested. The Plan 
has approved 2 of each of these codes. The Plan only covers 2 of these codes per calendar year. Based on this 
information, we decided that the Plans rules for additional services are not covered. Therefore, we decided that 
the Plan does not have to pre-approve dental services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occupational therapy (OT) visits to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve OT visits. You say that the services should be covered because you feel they 
are best suited 
to meet the enrollees needs as they are not just occupational therapists but are trained in functional neurology 
and other areas as well. The Plan denied your request. The Plan says the enrollee is required to use an in-
network provider. The Plan also says there are network providers available who can provide the 
items/services at issue. 
 
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 
occupational therapy (OT) visits to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture (D5214) provided on January 4, 2022. 
 
You asked the Plan to pay for the partial denture. You say that you need the dentures to eat. The Plan denied 
your request. The Plan says a mandibular partial denture (D5214) is not covered by your routine dental 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
mandibular partial denture (D5214) provided on January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on 
February 10, 2022. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that both you and your dentist's 
office were informed multiple times by the Plan that the treating provider was in-network and services 
provided by him would be covered. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. 
 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 benefit for the requested item or service was exhausted on date of service February 10, 2022. 
Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) 
provided on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine dental care to be rendered by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON routine dental care. You say that the dentist you are requesting to see 
has been your dentist for 40 years. You also say that you would like to continue to see this dentist. The Plan 
denied your request. The Plan says your needs can be met in-network, and going OON is not medically 
necessary at this time. The Plan also says there are 45 in-network providers within a 50-mile radius of your zip 
code. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve routine 
dental care to be rendered by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hot or cold packs therapy (97010) billed on March 23, 2022. 
 
You asked the Plan to pay for hot or cold packs therapy (97010). You say that you have coverage for this 
procedure and your chiropractor should be paid immediately. The Plan denied your request. The Plan says CPT 
codes 98942 and 98943 are overturned. The Plan also says CPT code 97010 has a status code of B and is not 
separately payable. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Based on this information, 
we decided that Medicare rules for coverage of hot or cold packs therapy (97010) have not been met. 
Therefore, we decided that the Plan does not have to pay for hot or cold packs therapy (97010) billed on March 
23, 2022.