Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the gas (S9975) used on November 29, 2022. 
 
You asked the Plan to pay for the gas. You say that you have previously applied for the same reimbursement 
and were approved. The Plan denied your request. The Plan says that the Plan is no longer reimbursing gas. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. Medicare rules also say that in any circumstance in which an MA plan provides transplant services at 
a more distant location, the MA plan must provide reasonable transportation for the enrollee and a companion 
to the distant facility. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The records do not support the Plan's denial of payment. This means that the 
Plan has not provided a valid reason for denying payment of gas. You reasonably believed that the cost of gas 
is considered part of reasonable transportation costs. It is the burden of the Plan to substantiate their denial with 
evidence. In this case, the denial has not been substantiated so we must find in your favor. Therefore, we 
decided that the Plan has to pay for the gas (S9975) used on November 29, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, and 87798 
billed for date of service October 14, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the codes are 
inclusive to payment for other services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that codes 87798, 87641, and 87150, billed with the -XU modifier, is not supported. Specifically, the 
records do not show that these services were unusual, non-overlapping services. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. 
 
We find that codes 87481 and 87653 are column II codes to column I codes 87801 and 87150. The column II 
codes were not billed with a modifier to bypass the edit. Based on this information, we decided that Medicare 
rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 87150, 87481, 87641, 87653, and 87798 billed for date of service October 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE). 
 
You asked the Plan to pre-approve TTE. You say that this service is medically necessary. The Plan denied your 
request. The Plan says TTE is not medically necessary because there is no documentation that the patient has 
new or worsening symptoms of heart disease. 
 
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 TTE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Clinical guidelines do not support performing a TTE in the absence of any symptoms, signs, 
physical findings or significant change in the patients clinical condition. There is no supportive evidence for 
the medical necessity of TTE in this this patients clinical management.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transthoracic echocardiography (TTE).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection of non-compounded foam sclerosant; multiple 
incompetent truncal veins (36466 x2) and injection of non-compounded foam sclerosant; single incompetent 
extremity truncal vein (34656). 
 
You asked the Plan to pre-approve injections of non-compounded foam sclerosant. 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 follows Medicare rules. Medicare rules say that treatment of chronic venous insufficiency of the 
lower extremities is covered when specific criteria are met. 
 
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 injections of non-compounded foam 
sclerosant. Our reviewer says that the services are not medically necessary. Our physician reviewer found there 
is only one vein which meet criteria for sclerosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injections of non-compounded foam sclerosant have not been met. Therefore, 
we decided that the Plan does not have to pre-approve injection of non-compounded foam sclerosant; multiple 
incompetent truncal veins (36466 x2) and injection of non-compounded foam sclerosant; single incompetent 
extremity truncal vein (34656).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan of the brain.  
 
You asked the Plan to pre-approve a PET scan of the brain. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the medical records do not indicate the 
enrollee meets the diagnostic criteria of both Alzheimer's Disease (AD) and frontotemporal dementia (FTD). 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan of the brain. Our reviewer 
says the enrollee is not noted to have either AD or frontotemporal dementia. It is unclear if there is a form of 
dementia present. In as much, the requirements for coverage of this service would not be considered to be 
satisfied at this time. 
 
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 PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a PET scan of the brain.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve feeding tube supply kit (B4034) and formula (B4152) to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve feeding tube supply kit and formula to be provided by an OON provider. 
You say that the services are necessary. The Plan denied your request. The Plan says there are in-network 
providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
feeding tube supply kit (B4034) and formula (B4152) to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the cervical spine. 
 
You asked the Plan to pre-approve an MRI of the cervical spine. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the requested MRI of the cervical 
spine is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the cervical spine. Our 
physician reviewer found that absent a conservative trial of therapy including physical therapy, the medical 
necessity of the requested MRI of the cervical spine has not been established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the cervical spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a an MRI of the cervical spine.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 74176 and 74018 billed for date of service 
November 15, 2022. 
 
You asked the Plan to pay for procedure codes 74176 and 74018. You say that the enrollee received multiple 
exams on the date in question. 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 December 15, 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 procedure codes 74176 and 74018 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 74176 and 74018 billed 
for date of service November 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller (E2377) electrical harness 
(E2313) and electronic connection (E2311) and power seat elevation system (E2300). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that you are appealing for the group 3 
wheelchair with tilt and recline. The Plan denied your request. The Plan says the upgraded electronics are not 
medically necessary, and the seat elevator does not serve a primary medical purpose 
 
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 upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has diffuse weakness but is able to dress themselves. The enrollee has 
adequate upper extremity strength to manage standard power drive controls. The electronics 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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve expandable controller (E2377) electrical harness (E2313) and electronic 
connection (E2311) and power seat elevation system (E2300).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis. 
 
You asked the Plan to pre-approve Lucentis. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of Lucentis have been met. Specifically, medical records were requested but not received. Medical necessity cannot be established without this 
documentation. Therefore, we decided that the Plan does not have to pre-approve Lucentis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and testing to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a consultation and testing to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
a consultation and testing to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Yervoy for the enrollee.
You asked the Plan to pre-approve Yervoy. You say that this drug is medically necessary for the patient. The Plan denied your request. The Plan says that this drug is being requested for an off-label, not medically-accepted use.
Our Medical director looked at the case file and the reopen request. At issue is coverage for Yervoy. Our Medical Director states that there is insufficient support in the medical literature for the use of Yervoy for more than four cycles in the treatment of colon cancer. Our Medical Director found that the enrollee's condition does not meet criteria for coverage of Yervoy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Yervoy have not been met. Therefore, we decided that the Plan does not have to pre-approve Yervoy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the electronic connection between wheelchair controller and two 
or more power seating system motors, including all related electronics, indicator feature, mechanical function 
selection switch, and fixed mounting hardware (E2311). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says that the DME is not 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 DME. Our physician reviewer 
found the enrollee is functionally non-ambulatory and requires a power wheelchair for mobility and performing 
her basic daily activities. The enrollee cannot perform pressure relief independently due to weakness and spasticity and requires a power wheelchair with power tilt for adequate pressure relief and positioning. The 
enrollee also requires power elevating leg rests for positioning and the enrollee's lower extremity spasticity. 
The complexity of the enrollee's seating and positioning needs necessitates a more complex group 3 power 
wheelchair base. The electronic connection is necessary to operate the group 3 power wheelchair base and the 
two power wheelchair functions, power tilt and power elevating leg rests via a joystick. Therefore, the 
electronic connection (E2311) 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 DME have been met. Therefore, we decided that the Plan has to pre-approve 
the electronic connection between wheelchair controller and two or more power seating system motors, 
including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting 
hardware (E2311).  
 
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 outpatient intravenous insulin therapy (OIVIT). 
 
You asked the Plan to pre-approve OIVIT. You say that the services are necessary. The Plan denied your 
request. The Plan says the requested services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS determines that OIVIT is not reasonable 
and necessary for any indication under section 1862(a)(1)(A) of the Social Security Act.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of OIVIT have not been met. Therefore, we decided that the Plan does not have to pre-approve 
outpatient intravenous insulin therapy (OIVIT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a functional electrical stimulator.
You asked the Plan to pre-approve a functional electrical stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not reasonable and necessary to treat your condition.
Our Medical director looked at the case file and the reopen request. At issue is coverage for a functional electrical stimulator. Our Medical Director states that the clinical documentation in the case file does not support that a functional electrical stimulator is medically reasonable and necessary for the enrollee in this case. Our physician reviewer found that your condition does not meet criteria for coverage of a functional electrical stimulator. 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 functional electrical stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a functional electrical stimulator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet block injection (64492). 
 
You asked the Plan to pre-approve the facet block injection. You say that the service is medically necessary. 
The Plan denied your request. The Plan says Medicare only allows two joints bilaterally to be injected. 
 
The Plan must follow Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, 
are allowed per session per spine region. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the facet block injection have not been met. Specifically, the member was approved for two levels 
of facet block injection, the third is not allowed. Therefore, we decided that the Plan does not have to pre-
approve the facet block injection (64492).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0245U billed for date of service June 3, 
2022.  

You asked the Plan to pay for procedure code 0245U. You say that this is medically necessary testing that 
should be covered. The Plan denied your request. The Plan says payment for code 0245U is bundled into 
payment for code 0018U. 
 
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 0245U 
is a column II code to column I code 0018U with a modifier indicator of 0. The column II code is therefore not 
payable. 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 0245U billed for date of service June 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT capture and interpretation with limited field 
of view  less than one whole jaw (D0364) provided on December 7, 2022. 
 
You asked the Plan to pay for dental services. You say that you are requesting to have the denial overturned 
with payment and waiving of fees due to no other available provider within our location and the services 
provided are included in your coverage plan. The Plan denied your request. The Plan says this service is not 
covered under your Plan. 
 
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. Cone beam CT capture and 
interpretation with limited field of view  less than one whole jaw (D0364) is not covered under the Plans 
dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0364 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for cone beam CT 
capture and interpretation with limited field of view  less than one whole jaw (D0364) provided on December 
7, 2022.