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

 
We decided that the Plan does not have to pay for the disposable drug delivery system (A4305) and infusion 
supplies not used with external infusion pump (A4223) provided from October 4, 2022, to October 6, 2022. 
 
You asked the Plan to pay for the disposable drug delivery system and infusion supplies. You say that you 
would like to be reimbursed for the underpaid charges. The Plan denied your request. The Plan says these 
services are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems are non-
covered devices, and drugs and supplies used with disposable drug delivery systems are also non-covered 
items. 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the disposable drug delivery system and infusion supplies have not been met. Therefore, we 
decided that the Plan does not have to pay for the disposable drug delivery system (A4305) and infusion 
supplies not used with external infusion pump (A4223) provided from October 4, 2022, to October 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically stable and 
needs to be transferred to an LTACH versus a lower level of care or remaining in the hospital. You say the 
enrollee's condition has stabilized, and they will require a multi-disciplinary approach for an extended period 
of time. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for care in an 
LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care setting. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the pulse oximeter purchased on May 31, 2022. 
 
You asked the Plan to pay for the pulse oximeter purchased on May 31, 2022.. You say that your doctor had 
you purchase the pulse oximeter due to the fact that you had contracted COVID-19 at the time. The Plan denied 
your request. The Plan says that a Pulse Oximeter device is not a Medicare covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that ear or pulse oximetry for oxygen saturation will 
be considered medically necessary when the patient has a condition resulting in hypoxemia and there is a need 
to assess the status of a chronic respiratory condition, supplemental oxygen requirements and/or a therapeutic 
regimen. 
 
We looked at the file and Medicare rules. The record shows that you purchased this pulse oximeter because you 
had COVID-19. COVID-19 can make it more difficult for one to breathe with lower levels of oxygen in your 
blood. Based on this information, we decided that Medicare rules for coverage of the pulse oximeter purchased 
on May 31, 2022. have been met. Therefore, we decided that the Plan has to pay for the pulse oximeter 
purchased on May 31, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 30, 
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. The code at issue 
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 October 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insulin infusion pump (code S1034) and continuous 
glucose monitor (CGM). 
 
You asked the Plan to pre-approve insulin infusion pump and CGM. You say that this is recommended for the 
enrollee. The Plan denied your request. The Plan says infusion pumps other than code E0784 will be 
automatically denied, and the enrollee is already approved for a Dexcom G6 CGM for the duration of their Plan 
enrollment. 
 
The Plan must follow Medicare rules. Medicare rules say that infusion pumps other than pump code E0784 will 
be automatically denied as not reasonable and necessary. Medicare rules state that equipment may not be 
replaced except in cases of loss, irreparable damage, or irreparable wear beyond the reasonable useful lifetime 
of the item. 
 
We looked at the file and Medicare rules. You have requested an insulin infusion pump other than code E0784, 
which is automatically denied by Medicare as not reasonable and necessary. Additionally, the enrollee has already been approved for use of a CGM for the duration of their Plan enrollment. The record does not show 
that the existing CGM has experienced loss, irreparable damage, or irreparable wear beyond its reasonable 
useful lifetime to warrant replacement. Based on this information, we decided that Medicare rules for coverage 
of insulin infusion pump and CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an insulin infusion pump (code S1034) and continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear provided on July 20, 2022. 
 
You asked the Plan to pay for the eyewear. You say that you are requesting reimbursement for the eyewear. 
The Plan denied your request. The Plan says the benefit limit is exhausted. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to a $400 allowance. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid the $400 allowance for the eyewear. 
Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. 
Therefore, we decided that the Plan does not have to pay for the eyewear provided on July 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression devices (E0675, E0673). 
 
You asked the Plan to pay for the pneumatic compression devices. You say that the items were medically 
necessary. The Plan denied your request. The Plan says the items were not used in a home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the pneumatic compression devices was used in an ambulatory surgical center. Therefore, 
we decided that the Plan does not have to pay for the pneumatic compression devices (E0675, E0673).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis. 
 
You asked the Plan to pre-approve the CT scan. You say that the enrollee has persistent wound irritation. The 
Plan denied your request. The Plan says the documentation did not show justification for the CT scan. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 the CT scan. Our reviewer says that the 
CT scan of the abdomen and pelvis is not medically necessary. Our physician reviewer found that the record 
indicates that the enrollee underwent laparoscopic partial colectomy and has skin dehiscence at a port site. The 
record indicates that the enrollee is tolerating diet, is afebrile and otherwise doing well. The provided records 
are insufficient to support the medical necessity or reasonableness, as defined by Medicare rules, of the 
requested service at this time. The elements of the coverage criteria are not satisfied. 
 
  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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on October 18, 
2022, to October 24, 2022. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says this claim has been processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140) provided on October 18, 2022, to October 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid (V5298) provided on September 15, 2022. 
 
You asked the Plan to pay for a hearing aid (V5298). You say that you have used the same audiologist's office 
for the last 25 years and for all 3 of your previous devices. The Plan denied your request. The Plan says there is 
no coverage if hearing aids, or related services are received from an out-of-network provider. The Plan also 
says that the hearing benefit is not covered if the services are not registered in advance. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when ordered through providers through the Plan hearing.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of a hearing aid (V5298) have not been met. Therefore, we decided that the Plan does not have to pay 
for a hearing aid (V5298) provided on September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95999 provided on May 17, 2022. 
 
You asked the Plan to pay for procedure code 95999. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 looked at the file and Medicare rules. The file shows that procedure code 95999 was submitted for train-of-
four monitoring. Train-of-four monitoring is bundled with the intraoperative neuromonitoring of 
electromyography (EMG) or motor evoked potentials (MEP) and is not separately payable. Therefore, we 
decided that the Plan does not have to pay for procedure code 95999 provided on May 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the adjustable angle footplate (K0040) heel loop/holder, 
any type (E0951) wheel lock brake extension (handle) (E0961) adjustable height, detachable armrest, complete 
assembly (E0973). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that please review the attached appeal 
request for the enrollee's wheelchair. The Plan denied your request. The Plan says the additional for wheelchair 
accessories are not considered medically necessary since all the accessories come with approved CPT code 
E1161. 
 
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. CPT code E1161, which was overturned by the Plan, is considered a 
complete wheelchair base. Therefore, there is no need for additional accessories that already come with the 
complete chair. Based on this information, we decided that Medicare rules for coverage of the wheelchair 
accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve the adjustable 
angle footplate (K0040) heel loop/holder, any type (E0951) wheel lock brake extension (handle) (E0961) 
adjustable height, detachable armrest, complete assembly (E0973).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94761 billed for August 12, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 94761 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that services with status indicator N are paid under the 
OPPS, but their payment is packaged into payment for a separately paid service. 
 
We looked at the file and Medicare rules. Billed procedure code 94761 has an OPPS status indicator of N and 
payment is packaged into a separately paid service. Therefore, we decided that the Plan does not have to pay 
for procedure code 94761 billed for August 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that this is essential for the enrollee. The Plan denied 
your request. The Plan says a ventilator is not covered by Medicare for this purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure (CPAP or BiPAP) therapy, regardless of the underlying medical condition, 
shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an extraction (D7210) provided on 
November 4, 2022. 
 
You asked the Plan to waive the coinsurance for an extraction. You say that you disagree with these charges. 
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 50% 
coinsurance for extractions/in-network.  
 
You have been asked to pay a 50% coinsurance of the allowed amount for an extraction. The total allowed 
amount is $270. The total amount you are being asked to pay is $135 ($270 x 50% = $135). This item/service 
falls within the extractions/in-network 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 coinsurance for 
an extraction (D7210) provided on November 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression devices (E0675, E0763). 
 
You asked the Plan to pay for the pneumatic compression devices. You say that the items were medically 
necessary. The Plan denied your request. The Plan says these items were not used in a home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the pneumatic compression devices was used in an ambulatory surgical center. Therefore, 
we decided that the Plan does not have to pay for the pneumatic compression devices (E0675, E0763).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee is not a candidate for platinum-based 
chemotherapy. The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that the 
requested use of Keytruda is not medically necessary. Our physician reviewer found the Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. Therefore, the reviewer found that the requested use of Keytruda is not 
medically reasonable or 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation with a medicinal agent  per quadrant 
(D4921) provided on January 8, 2021. 
 
You asked the Plan to pay for the gingival irrigation with a medicinal agent. You say that you don't feel you 
had an adequate deep cleaning. The Plan denied your request. The Plan says this service is not covered under 
your 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 the 
gingival irrigation with a medicinal agent  per quadrant (D4921) provided on January 8, 2021.  
 
Your complaint about the claim for the periodontal scaling and root planing (D4341) causing a subsequent 
service to deny for frequency limitations and feeling that the service provided was not adequate are not valid appeals for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
September 19, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service September 19, 2022.