Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromonitoring services (95999) provided on June 2, 2022. 
 
You asked the Plan to pay for the neuromonitoring services. You say that his service was medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed code. 
 
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 95999 is unlisted neurological or neuromuscular 
diagnostic procedure. 
 
We find that CPT code 95999 is not supported in the medical record. Specifically a CPT code for Train-of-four 
does not exist, and is considered integral to intraoperative neuromonitoring and/or administration of anesthesia 
and, therefore, is not separately reportable. Based on this information, we decided that Medicare rules for 
coverage of the neuromonitoring services have not been met. Therefore, we decided that the Plan does not have 
to pay for neuromonitoring services (95999) provided on June 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218). 
 
You asked the Plan to pre-approve a fluid circulating cold pad with pump. You say that you had knee surgery 
on February 13, 2023. You were prescribed a cooling compression unit and your provider stated that you must 
have it. You are in terrible pain, and you would like to walk after this procedure by abiding to what the doctor 
wants. The Plan denied your request. The Plan says the requested device is not covered by Medicare or the 
Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The LCD confirms that the requested device will be denied as not 
reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of a fluid 
circulating cold pad with pump have not been met. Therefore, we decided that the Plan does not have to pre-
approve a fluid circulating cold pad with pump (E0218).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Special Supplemental benefit for Chronically Ill 
(SSBCI). 
 
You asked the Plan to pre-approve the SSBCI. You say that the service is medically necessary. The Plan denied 
your request. The Plan says there is no documentation that the member meets criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SSBCI have not been met. Specifically, we have confirmed that you do not have one of the 
eligible conditions listed in the Evidence of Coverage. Specifically, medical records indicating you have a 
qualified condition for this benefit were not submitted. Therefore, we decided that the Plan does not have to 
pre-approve the Special Supplemental benefit for Chronically Ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alert or alarm device (A9280). 
 
You asked the Plan to pre-approve an alert device. You say that you need the necklace due to your medical 
disability needs and your doctor recommended the device. The Plan denied your request. The Plan says 
Medicare and the Plan do not cover alert devices, because they are not primarily medical in nature and are 
considered a convenience item. 
 
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 alert or alarm device (A9280).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental exam (D0120), bitewing x-rays (D0274) and a 
dental cleaning (D1110) provided on May 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you went to the same dentist and never received 
notice that the provider was changed. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider and are not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a dental exam (D0120), bitewing x-rays (D0274) and a dental cleaning (D1110) provided on May 5, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrodes (A4595) provided on April 28, 2022. 
 
You asked the Plan to pay for the electrodes. You say that you want the Plan to pay for the item. The Plan 
denied your request. The Plan says the proof of delivery did not include an order number or details to 
corroborate the delivery ticket submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. All that we received was a third-party delivery service 
tracking sheet. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the electrodes (A4595) provided 
on April 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthotic (L8702). 
 
You asked the Plan to pre-approve the MyoPro orthotic. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is considered experimental. 
 
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 MyoPro orthotic. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the MyoPro Orthosis is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes. It is not the standard of care for this patient's 
condition or in widespread use for this patient's condition based on scientific evidence. There is insufficient 
evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient or that 
this device will increase participation in bimanual activities. 
 
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 MyoPro orthotic have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the MyoPro orthotic (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (including elevation of a full thickness 
flap and closure) upper right and left, lower right and left (D4260). 
 
You asked the Plan to pre-approve dental services. You say that you do not understand why the requested 
services are denied. 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. Osseous surgery (including 
elevation of a full thickness flap and closure) upper right and left, lower right and left (D4260) is not covered 
under the Plans dental benefits. 
 
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 
osseous surgery (including elevation of a full thickness flap and closure) upper right and left, lower right and 
left (D4260).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service November 
15, 2022. 
 You asked the Plan to pay for the billed services. You say that the physician provided care for an unstable 
patient with significant problems. The Plan denied your request. The Plan says an inappropriate place of 
service code was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The file shows that the enrollee was an outpatient at the time the services at 
issue were provided. The medical records indicate that the evaluation and management service at issue resulted 
in the decision to admit the enrollee as an inpatient. 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 code 99233 billed for date of service November 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power wheelchair rental provided on December 8, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for a power wheelchair rental provided by an out-of-network provider. You say that 
this was necessary. The Plan denied your request. The Plan says this provider was not contracted with the Plan. 
 
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 a power wheelchair rental provided on December 
8, 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 knee scooter (E0118). 
 
You asked the Plan to pre-approve a knee scooter. You say that you recently broke your foot and are currently 
wearing a boot. You are experiencing pain and your fingers are bruised. You are unable to put any weight on 
your foot and it is difficult to get around. The Plan denied your request. The Plan says the device does not meet 
Medicare NCD 280.1 criteria as listed above. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The NCD confirms that the knee scooter is not listed as a covered 
benefit. Based on this information, we decided that Medicare rules for coverage of a knee scooter have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a knee scooter (E0118).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services provided on July 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on November 01, 2022. 
 
You asked the Plan to pay for injections. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for injections provided on 
November 01, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefit for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no documentation that you meet criteria for approval of these benefits. 
 
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. Medicare rules also say that there is a special supplemental benefit for enrollees with an eligible 
chronic condition. 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 SSBCI have been met. Specifically, 
multiple attempts were made by the Plan to the providers office to obtain medical records, but additional 
supporting documentation was not received. Therefore, we decided that the Plan does not have to pre-approve 
special supplemental benefit for the chronically ill (SSBCI).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  ambulance transport and supplies provided on December 28, 
2021. 
 
You asked the Plan to pay for the ambulance transport and supplies provided. You say that the medical records 
provided support the need for the ambulance transport. The Plan denied your request. The Plan says the 
ambulance transport services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 pay for the ambulance transport and supplies 
provided. Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer 
found the transportation via ambulance from the hospital to the enrollee's assisted living facility was not 
medically necessary. The enrollee did not require the expertise of trained personnel or the equipment available 
only on an ambulance in order to effectuate a safe transport. Transportation could have been provided by other 
means (stretcher van, wheelchair van) without endangering the enrollee's 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 ambulance transport and supplies provided have not been met. Therefore, 
we decided that the Plan does not have to pay for  ambulance transport and supplies provided on December 28, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the echocardiography (93306). 
 
You asked the Plan to pre-approve the echocardiography. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service 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 the echocardiography. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no evidence provided that would support the need for stress echocardiography. 
 
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 echocardiography have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the echocardiography (93306).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from November 28, 2020, 
through January 6, 2021. 
 
You asked the Plan to pay for the medical services. You say that you are requesting reimbursement of services 
rendered because the enrollee received ten hours of hospice care when they required 24-hour daily care. The 
Plan denied your request. The Plan says the enrollee was enrolled in hospice at the time of services. The Plan 
states per Medicare guidelines, the enrollee's services should be billed under Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was enrolled in hospice from November 28, 2020, through January 7, 2021; therefore, the enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided 
that the Plan does not have to pay for the medical services provided from November 28, 2020, through January 
6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Sensor. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 Sensor. The Plan denied your request. The Plan says 
you do  not require insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the Freestyle 
Libre 2 Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle 
Libre 2 Sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20610, 77002, and J7324 billed for date of 
service October 24, 2022. 
 
You asked the Plan to pay for the billed services. You say that the records prove medical necessity. The Plan 
denied your request. The Plan says the diagnosis codes were inappropriately attached to all procedure codes. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim shows that the diagnosis code indicating a right-side condition, 
M25.561, was used for procedures performed on the left side (20610-LT and J7324-LT). In the same way that 
the diagnosis code indicating a left-side condition, M25.562, was used for procedures performed on the right 
side (20610-RT and J7324-RT). Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. 
 
We also find that code 77002 is an add-on code. Because the primary procedure code, 20610, is not payable in 
this case, the add-on code is also not payable. 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 20610, 77002, and J7324 billed for date of service October 24, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve at-home physical therapy (PT) visits (97110, 97162) to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve at home PT visits. You say that there is no in-network provider available for 
this service. The Plan denied your request. The Plan says you must receive your care from a network provider. 
There are in-network providers available for this service. 
 
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 
at-home physical therapy (PT) visits (97110, 97162) to be provided by an out-of-network (OON) provider.