Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 73110, 
71101) provided to the enrollee on April 22, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says these codes have a status indicator of "V." 
 
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 73110 and 71101 are not supported in the medical record. Specifically, these codes 
have a status indicator of V, which means they are not separately payable during a clinic or emergency 
department visit. Based on this information, we decided that Medicare rules for coverage of the services have 
not been met. Therefore, we decided that the Plan does not have to pay for emergency department services 
(procedure code 73110, 71101) provided to the enrollee on April 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a basket for a power operated vehicle. 
 
You asked the Plan to pre-approve a basket for a power operated vehicle. You say that this is necessary for 
when you are shopping. The Plan denied your request. The Plan says this item is not covered by Medicare or 
the Plan. 
 
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 a basket for a power operated vehicle.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee has lumbar issues. The Plan denied your 
request. The Plan says that other documentation of red flags has not been provided. 
 
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 the MRI. Our physician reviewer found 
that the enrollee has low back pain. She has been treated with medical therapy and steroid injections. She 
underwent an MRI of the lumbar spine 1 year ago, but presently has an expanding mass on the lower spine. On 
exam she has an antalgic gait and an L2-L3 6cm mass. The review has determined that the requested MRI of 
the LS spine with contrast is medically necessary and reasonable. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the lumbar spine.  
 
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 pay for an office visit provided on January 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal.  The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to 
pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit 
provided on January 26, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve a maxillary partial denture. You say that you would like to receive approval 
for this partial. 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 August 26, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two abutment supported porcelain/ceramic crowns 
(D6058 x2) and two implant supported porcelain/ceramic crowns (D6065 x2). 
 
You asked the Plan to pre-approve the abutment and implant crowns. The Plan denied your request. The Plan 
says this service is not covered under the enrollee's benefit 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. 
 
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 two 
abutment supported porcelain/ceramic crowns (D6058 x2) and two implant supported porcelain/ceramic 
crowns (D6065 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that your old dentures did not fit properly. 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 October 1, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra wide heavy duty hospital bed (E0303). 
 
You asked the Plan to pre-approve the extra wide heavy duty hospital bed. You say that the hospital bed is 
medically necessary. The Plan denied your request. The Plan says coverage criteria for this type of bed has not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed (E0301, 
E0303) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the 
beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds. 
 
We looked at the file and Medicare rules. The records show that the enrollee weighs less than 350 pounds. 
Based on this information, we decided that Medicare rules for coverage of the extra wide heavy duty hospital 
bed have not been met. Therefore, we decided that the Plan does not have to pre-approve an extra wide heavy 
duty hospital bed (E0303).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 100 one-way non-emergency 
transportation trips (A0100). 
 
You asked the Plan to pre-approve an additional 100 one-way non-emergency transportation trips (A0100). 
You say that you still need approximately 100 rides to finish out the year. The Plan denied your request. The 
Plan says the 2022 EOC clearly states 100 one-way trips per calendar year. The Plan also says that the 101st 
and beyond is not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 100 one-way routine ground transportation trips per year.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 100 one-way non-emergency transportation 
trips (A0100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) coded E0652 
and full leg sleeve. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an E0652 PCD 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not show that the 
enrollee has tried and failed at least four weeks of regular, daily, multiple-hour home usage of a basic 
pneumatic compression device after careful, in-person fitting, training and supervision by a technician who is 
skilled in and who regularly and successfully uses the appliance provided. The criteria for coverage are not 
met; therefore, the services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a pneumatic compression device (PCD) coded E0652 and full leg sleeve.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 standard power wheelchair (K0823). 
 
You asked the Plan to pre-approve a Group 2 power wheelchair. You say that a Group 2 power wheelchair is a 
medical necessity for you. The Plan denied your request. The Plan says rules for coverage for a power 
wheelchair 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 Group 2 standard power wheelchair (K0823).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox (J0585) and chemodenervation of muscle(s) 
(64616). 
 
You asked the Plan to pre-approve Botox and chemodenervation of muscle(s). You say that Botox is well 
studied in the treatment of the enrollee's condition, and will likely be a long-term treatment for them. The Plan 
denied your request. The Plan says the enrollee does not have any stated contraindications to the preferred 
products. The Plan also says the enrollee has not tried any of the preferred agents.  
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Botox and chemodenervation of 
muscle(s). Our reviewer says that the enrollee does not meet the criteria for coverage for Botox. Our physician 
reviewer found there is no indication that the enrollee has tried and failed the required drug(s). Our reviewer 
also found that there is no indication that the Plan's required drug(s) would likely be less effective and/or likely 
have adverse effects 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 Botox and chemodenervation of muscle(s) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Botox (J0585) and chemodenervation of muscle(s) (64616).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says this item is not a covered 
benefit under your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6533.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve the home health physical therapy (PT) services (G0151 X 10). 
 
You asked the Plan to pre-approve the home health physical therapy services. You say that the services are 
necessary. The Plan denied your request. The Plan says that your records do not support the need for a skilled 
physical therapist to make more home visits at this time. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home health physical therapy 
services. Our physician reviewer found the clinical documentation shows that you have had multiple recent 
falls, are home bound, require assistive device training/evaluation and physical assist with mobility; thus, the 
professional assessment and treatment from a skilled physical therapist would be required and 10 home health 
PT visits 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 home health physical therapy services 
have been met. Therefore, we decided that the Plan has to pre-approve the home health physical therapy (PT) 
services (G0151 X 10).  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on January 17, 2022. 
 
You asked the Plan to pay for anesthesia services. The Plan denied your request. The Plan says Medicare is 
responsible for coverage claims under hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 16, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for anesthesia services 
provided on January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient visit provided on May 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for outpatient visit. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
  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 outpatient visit provided on May 24, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 3, 2022 billed with 
codes 81210, 81120, 81121, 81235, 81245, 81270, 81272, 81275, 81276, 81310, 81311, 81315, 81194, and 
81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says a review of the medical literature and 
clinical practice guidelines does not support the clinical utility of large multigene panel testing for 
hematological malignancies. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 3, 2022 billed with codes 81210, 81120, 81121, 81235, 81245, 81270, 81272, 81275, 81276, 81310, 
81311, 81315, 81194, and 81351.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the stress test (CPT code 93351), doppler 
echocardiography (93320), doppler echocardiography color flow velocity mapping (93325) and 
echocardiography, transthoracic (93306). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 services. Our physician reviewer 
found there is no evidence provided that would support the need for stress echocardiography. In summary, 
there is insufficient documentation to support the medical necessity for the requested stress echocardiography 
in this 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the stress test (CPT code 93351), doppler echocardiography (93320), doppler 
echocardiography color flow velocity mapping (93325) and echocardiography, transthoracic (93306).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PuraPly AM skin substitute (CPT code Q4196) and the 
application of the skin substitute (CPT code 15276). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found infection prevention is not an indication for this product and there is poor circulation to the area 
making skin grafting less likely to benefit the enrollee as it is less likely to heal properly after application. 
Therefore, due to insufficient support made for this request, the PuraPly will be 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve PuraPly AM skin substitute (CPT code Q4196) and the application of the skin substitute 
(CPT code 15276).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on February 11, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the providers taxonomy code (163WR0006X) is not found within the Medicare Provider 
Supplier to Healthcare Provider Taxonomy Crosswalk. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are 
enrolled in the Medicare program..  
 
The rendering provider is not eligible to bill Medicare. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for surgical services provided to the enrollee on February 11, 2022.