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

 
We decided that the Plan does not have to pre-approve a neurostimulator. 
 
You asked the Plan to pre-approve the requested services. You say that the goal is to help alleviate pain. The 
Plan denied your request. The Plan says the request is not covered by Medicare. 
 
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 requested auricular stimulator is not considered an implanted 
device. The device does not require surgical implantation and/or incision into the central nervous system or 
targeted peripheral nerve. Based on this information, we decided that Medicare rules for coverage of the 
requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
neurostimulator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
16, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 16, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the services provided were medically necessary. The 
Plan denied your request. The Plan says the services must be obtained from an in-network provider. 
 
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 September 26, 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 power operated scooter. 
 
You asked the Plan to pre-approve a power operated scooter. You say that [Enter appellant's argument from 
appeal letter, e.g. "...you need SNF care."] The Plan denied your request. The Plan says [Enter plan denial 
rationale, e.g. "...rules for SNF care have not been met."] 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power operated scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (D7140 and D7210), primary closure of a sinus 
perforation (D7261), and deep sedation (D9222 and D9223) provided by an out-of-network provider on June 
14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendered dental services are not covered 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. 
 
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 
extractions (D7140 and D7210), primary closure of a sinus perforation (D7261), and deep sedation (D9222 and 
D9223) provided by an out-of-network provider on June 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that if you had been transported by the 
ambulance your copayment would have been only $75. You also say that it doesn't make sense the claim was 
denied and you are responsible because the service is not covered. The Plan denied your request. The Plan says 
these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 15, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests provided on 
April 22, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $250 
copayment for outpatient diagnostic tests/Medicare-covered diagnostic.  
 
You have been asked to pay a $250 copayment for outpatient diagnostic tests. This item/service falls within the 
outpatient diagnostic tests/Medicare-covered diagnostic 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 diagnostic tests provided on April 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that your legs have filled with 
water, and they are in pain. It is difficult to lay down or even turn around. You wear compressions all day and 
raise your legs as high as possible and the device is needed to help your condition. The Plan denied your 
request. The Plan says the submitted clinical information does not show that you have lymphedema extending 
onto the chest, trunk and/or abdomen. In addition, the submitted clinical notes do not show that you have 
abdominal/truncal edema on exam. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is a fall risk after open-heart surgery. 
The enrollee needs help with daily living activities and lives alone. 
 The Plan denied your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs 
can be met at a lower level of care such as a skilled nursing facility (SNF), home with home health services or 
home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the clinical documentation shows functional impairments, but there are no complex 
functional deficits specified. This means the enrollee does not require intense therapy or interdisciplinary team 
management of rehabilitation in an IRF setting. The medical record does not show any active medical 
comorbidities which means the enrollee would not be expected to require continued inpatient hospitalization 
during rehabilitation. In conclusion, the complexity of the patient's documented nursing, medical and 
rehabilitation needs would not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation 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.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional occupational therapy visits. 
 
You asked the Plan to pre-approve 12 additional occupational therapy visits. You say that outpatient 
occupational therapy visits are medically necessary due to non-traumatic intracranial hemorrhage. The Plan 
denied your request. The Plan says an additional 12 visits have been approved and the remaining 12 visits are 
not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional occupational therapy 
services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of your condition. Our physician reviewer found that the complexity of your conditions does not 
require the skills of a professional therapist to achieve further improvement in your symptoms or functional 
status. Medical notes from your treating physician were not provided documenting the need for additional 
skilled occupational therapy services beyond what have been approved. Further utilization of the home exercise 
program is more appropriate unless additional documentation is provided showing necessity of further 
treatment.  
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 additional occupational therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the acute care services are necessary. The Plan 
denied your request. The Plan says based on Medicare guidelines and the information we have about your 
condition you do not meet all the requirements 
 
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 do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  You were admitted for urinary tract infection and a colo-vaginal fistula. Medical problems are stable. There are 
no complex nursing or rehabilitation needs. While the medical records support a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Positioning cushion/pillow/wedge, any shape or size, 
includes all components and accessories (E1390). 
 
You asked the Plan to pre-approve the positioning cushion. You say that you need the positioning cushion so 
that you can breathe while you sleep due to sleeping on your side. The Plan denied your request. The Plan says 
this item is 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 Positioning cushion/pillow/wedge, any shape or size, 
includes all components and accessories (E1390).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left heart catheter placement in coronary artery(s) for 
coronary angiography, including intraprocedural injection(s) for coronary angiography (93458). 
 
You asked the Plan to pre-approve a left heart catheterization. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the enrollee has a normal MPI stress test with nonangimal chest pain 
symptoms. A left heart catheterization 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 a left heart catheterization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee had a negative radionuclide stress test in 2021 to evaluate these 
symptoms. Documentation does not support the rationale for this invasive imaging study. Guidelines do not 
support a need for cardiac catheterization in this setting. As a result, at this time cardiac catheterization would 
not be considered medically appropriate and necessary in the enrollee's 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 a left heart catheterization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a left heart catheter placement in coronary artery(s) for coronary 
angiography, including intraprocedural injection(s) for coronary angiography (93458).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle, group 1 standard, patient 
weight capacity up to and including 300 pounds (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that the enrollee is homebound and unable to walk 
more than 200 feet with a wheeled walker. The enrollee would like to be able to get to the grocery store which 
is 2 blocks away. The Plan denied your request. The Plan says when a power scooter is only for use outside the 
home it is not considered to be covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle, group 1 standard, patient weight capacity up to and including 
300 pounds (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat elevation system (E2300), a power wheelchair 
expandable controller upgrade (E2377), an electronic connection (E2311) and a harness for an upgraded 
expandable controller (E2313). 
 You asked the Plan to pre-approve a seat elevation system (E2300), a power wheelchair expandable controller 
upgrade (E2377), an electronic connection (E2311) and a harness for an upgraded expandable controller 
(E2313). You say that the requested seat elevation system (E2300), power wheelchair expandable controller 
upgrade (E2377), electronic connection (E2311) and harness for an upgraded expandable controller (E2313) 
are medically necessary. The Plan denied your request. The Plan says the requested seat elevation system 
(E2300), power wheelchair expandable controller upgrade (E2377), electronic connection (E2311) and harness 
for an upgraded expandable controller (E2313) are 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 a seat elevation system (E2300), a 
power wheelchair expandable controller upgrade (E2377), an electronic connection (E2311) and a harness for 
an upgraded expandable controller (E2313). Our reviewer says that the requested seat elevation system 
(E2300), power wheelchair expandable controller upgrade (E2377), electronic connection (E2311) and harness 
for an upgraded expandable controller (E2313) are not medically necessary. Our physician reviewer found a 
power seat elevation system is considered not medically necessary. The enrollee has strength and mobility in 
right arm sufficient to manage standard switches per documentation. 
 
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 seat elevation system (E2300), a power wheelchair expandable controller 
upgrade (E2377), an electronic connection (E2311) and a harness for an upgraded expandable controller 
(E2313) have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat elevation 
system (E2300), a power wheelchair expandable controller upgrade (E2377), an electronic connection (E2311) 
and a harness for an upgraded expandable controller (E2313).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft (D4263) and surgical placement 
of implant body-endosteal implant (D6010). 
 
You asked the Plan to pre-approve dental services. You say that the service should be covered, you get one 
implant every 5 years. You already have a partial denture, and it did not work. The Plan denied your request. 
The Plan says you do not meet the requirements for D6010 implant for tooth #30 and bone replacement graft is 
not a covered service with the 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. The Plan covers dental 
services when the services are medically necessary and reasonable.  
 
  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 dental services. Our physician reviewer 
found the provided covered codes for treatment do not include those for dental implants. Even if indicated, Plan 
limitations do not provide coverage for the requested treatment.  Under the Plan there would be no coverage for 
the requested implant and graft. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone replacement graft (D4263) and surgical placement of implant body-endosteal implant 
(D6010).