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

 
We decided that the Plan does not have to pre-approve a functional electrical stimulator, transcutaneous 
stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified (E0770). 
 
You asked the Plan to pre-approve a functional electrical stimulator. You say that the device is medically 
necessary. The Plan denied your request. The Plan says The device is being denied because the Plan does not 
have evidence that it is 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 functional electrical stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested technology (FES) device has not been shown to lead to 
improved outcomes in the walking ability of patients with MS compared to AFOs. Direct comparison studies of 
the devices have not shown that the FES device leads to any meaningful improvements when compared to use 
of an AFO. As such it cannot be said that the requested device is otherwise the most appropriate service that 
can be provided to you at this time to address your clinical needs. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a functional electrical stimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a functional electrical stimulator, transcutaneous stimulation of nerve 
and/or muscle groups, any type, complete system, not otherwise specified (E0770).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on 
May 19, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service was medically 
necessary. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the 
enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 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 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 hospital discharge day management (99239) provided on 
May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment, methadone (G2067), and 
take-home supply of methadone (G2078) provided on March 6, 2022, to April 24, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the opioid treatment services. You say that you were not aware that authorization 
was required. You also say that the facility has billed many claims without authorization that have been paid. 
The Plan denied your request. The Plan says prior authorization was not obtained. The Plan also says that the 
enrollee's primary care physician did not refer them for the services.  
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 in this case is not a network provider with the Plan. 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 the medication assisted treatment, methadone (G2067), and take-
home supply of methadone (G2078) provided on March 6, 2022, to April 24, 2022, by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 
12, 2022. 
 
You asked the Plan to pay for the dental services. 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 June 10, 2021. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 
12, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on April 11, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the claim 
was billed with an inconsistent date of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The case file does not show that the lab service does not meet any of the exceptions outlined in the Medicare 
ruling. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding 
their decision to deny your request.  Therefore, we decided that the Plan has to pay for the laboratory services 
provided on April 11, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this device is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that due to the patient misleading the office of incorrect 
insurance, the office was unable to obtain authorization. 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 May 17, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that this device is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the requested device is considered 
experimental/investigational. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that at issue is the medical appropriateness and necessity of implantation of the 
wireless pulmonary artery pressure monitoring system CardioMEMS for management of congestive heart 
failure (CHF) in the enrollee. The CardioMEMS device was approved by the Food and Drug Administration 
(FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of 
pulmonary artery pressure in the management of patients with CHF. The clinical study on which FDA approval 
was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the 
CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in 
heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology 
literature is supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of 
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on February 25, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you think 
this service was covered before without transport to the hospital, and you would like this denial to be 
reconsidered. The Plan denied your request. The Plan says the ambulance was dispatched to your residence for 
hypoglycemia. The Plan also says you were treated and refused transport. 
 
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 February 25, 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 response and treatment with no 
transport (A0998) provided on February 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept (PI) services (A0432) provided on 
January 29, 2022. 
 
You asked the Plan to pay for the PI services. You say that you feel your situation was not in need of an 
ambulance intercept, and this should have been part of your ambulance copay. You also say that your insurance 
should cover this cost. The Plan denied your request. The Plan says your coverage does not provide for this 
ambulance service. 
 
 
 
 The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept (PI) services (A0432) provided on January 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have pre-approve Accucheck Softclix Lancets. 
 
You asked the Plan pre-approve Accucheck Softclix Lancets. You say that the Softclix lancets are less painful 
and more accurate. You say that you are a diabetic so you need to test multiple times per day and want to use a 
product that is as accurate as possible. The Plan denied your request. The Plan says lancets are limited to 
preferred products such as OneTouch manufactured by Lifescan. 
 
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 pay a $0 
copayment for each 30 day supply of Medicare-covered lancets which are limited to preferred products such as 
OneTouch manufactured by Lifescan: OneTouch delica Lancets, OneTouch Ultrasoft Lancets, and Lifescan 
Fine Point Lancets. 
 
 
 This item/service falls within the Diabetes Self-Management Training, Diabetic Services and Supplies benefit 
category. Therefore, we decided that the Plan does not have pre-approve the Accucheck Softclix Lancets.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 applications of 30 units Epifix or epicord, per square 
centimeter (Q4131) surgical preparation for skin replacement surgery, skin substitute grafts (15271). 
 
You asked the Plan to pre-approve Epifix grafting. You say that please review physician's orders and clinical 
notes attached. The Plan denied your request. The Plan says the enrollee had treatment with Epifix earlier this 
year. No information on how the wounds responded was received. There is not enough information about the 
results of the enrollee's treatment. 
 
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 Epifix grafting. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case the record indicates that the enrollee has chronic venous stasis ulcers for more than a year. The record indicates that the enrollee was previously treated with the requested product and additional 
treatments are requested. The provided documents do not indicate the efficacy of the previous treatment nor the 
rationale for the medical necessity of ongoing treatment with the same product. The record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The 
elements of the coverage criteria are not satisfied and the requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Epifix grafting have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 5 applications of 30 units Epifix or epicord, per square centimeter (Q4131) surgical 
preparation for skin replacement surgery, skin substitute grafts (15271).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and the limited 
oral evaluation-problem focused (D0140) provided on June 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the dental services were received from 
an out-of-network provider and are not covered. 
 
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 that the enrollee received the dental services from an out-of-network provider. Though the 
Plan offers a dental benefit in excess of Medicare coverage, the services provided 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 the panoramic radiographic image (D0330) and 
the limited oral evaluation-problem focused (D0140) provided on June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99070 billed for date of service May 17, 
2022. 
 
You asked the Plan to pay for procedure code 99070. You say that this denial does not seem logical and you 
have provided records to support payment. The Plan denied your request. The Plan says procedure code 99070 
is considered bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99070 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99070 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99070 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99070 billed for date of service May 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not require the power options. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications. 
 
A group 3 power wheelchair with power tilt, recline, and elevating leg rests were requested. 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 requested services. Our physician reviewer found 
that the enrollee has a history of multiple strokes. He is dependent in transfers and non-ambulatory. His last 
stroke was in 2019. He has been using a manual wheelchair. There is no intermittent catheterization, no 
ventilator, and no skin issues despite having a stroke 3 years and being dependent in a wheelchair since. This is 
evidence he is not high risk for skin breakdown. Therefore, the requested wheelchair is 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a group 3 power wheelchair with multiple power options.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on June 1, 2020. 
 
You asked the Plan to pay for the dental services. You say that you contacted the Plan and were told to have the 
dental office bill the Plan for the services provided. You also say that you did not receive a bill for over a year, 
and are now being told there are timely filing limits. The Plan denied your request. The Plan says you received 
non-Medicare-covered dental services on June 1, 2020, and the Plan received your request for reimbursement 
May 28, 2022. The Plan also says that this request was received after the 365-day timely filing limit for dental 
reimbursements. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the dental services was not filed until May 28, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the dental services provided on June 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral evaluation 
(D0150) and five surgical extractions (D7210) to be performed by an oral 
surgeon. 
 
You asked the Plan to pre-approve an oral evaluation and five surgical 
extractions to be performed by an oral surgeon. You say that the services 
are necessary. The Plan denied your request. The Plan says based on the 
documentation provided, coverage criteria has not been met. 
 
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 states that covered 
dental services must be performed by a participating general dentist 
 
We looked at the file and Medicare rules. Based on this information, we 
decided that the Plan's rules for coverage of an oral evaluation and five 
surgical extractions to be performed by an oral surgeon have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an 
oral evaluation (D0150) and five surgical extractions (D7210) to be 
performed by an oral surgeon.