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

 
We decided that the Plan does not have to pre-approve replacement of sacral nerve stimulator for urinary 
incontinence (InterStim) (CPT code 64561). 
 
You asked the Plan to pre-approve the InterStim. You say that you require a newer version of an InterStim 
device that is compatible with magnetic resonance imaging (MRI) so that you can have evaluation of a foot 
injury. The Plan denied your request. The Plan says a replacement is not necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the InterStim have not been met. Replacement of medical 
equipment is covered if the equipment is at least 5 years old. Your current InterStim device is not 5 years or 
older. It was placed in August of 2019. The plan contacted your provider's office and confirmed that an MRI of your foot is not required, and you may have a computed tomography (CT) scan instead to properly evaluate 
your foot injury. Your current device is compatible with a CT scan. Therefore, we decided that the Plan does 
not have to pre-approve replacement of sacral nerve stimulator for urinary incontinence (InterStim) (CPT code 
64561).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the rental of high frequency chest wall oscillation 
(HFCWO) system, includes all accessories and supplies (CPT code E0483). 
 
You asked the Plan to pre-approve the DME. You say that prior to having your insurance, the enrollee was 
authorized and approved for E0483. You state the enrollee was trained on August 9, 2021, and has been using 
it since and it would be unfair not to cover the device. You state the enrollee's physician attests that therapy is 
medically necessary and that the enrollee should continue therapy. The Plan denied your request. The Plan says 
this request cannot be approved because the enrollee has chronic obstructive pulmonary disease (COPD), they 
do not have bronchiectasis (area(s) of collapsed lung that have been shown on imaging), and they do not have a 
muscle or nerve problem that keeps the enrollee from clearing mucus from their lungs. The Plan states this 
system is considered not medically necessary for other lung conditions by Medicare and is therefore, not 
covered for emphysema. 
 
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 DME. Our physician reviewer 
found coverage criteria for a HFCWO are not met. This enrollee has COPD, and does not have bronchiectasis, 
cystic fibrosis, or neuromuscular disease. This treatment has not been shown in high quality-controlled trials to 
be of benefit in the treatment of COPD. The denial is upheld. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the rental of high frequency chest wall oscillation (HFCWO) system, includes all accessories 
and supplies (CPT code E0483).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested procedure fills a 
treatment gap for patients that do not receive adequate relief from traditional conservative methods and don't 
have instability to indicate fusion is the appropriate treatment. The Plan denied your request. The Plan says this 
service is not widely used and not generally accepted for the suggested use as reported in nationally recognized 
peer-reviewed medical literature. 
 
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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are multiple plausible pathologic sources of significant pain generation. The 
intermittent radiating midline back pain and intact neurologic exam were/are all non-specific to any pathologic 
entities. Overall, documentation is lacking regarding reasonably detailed and/or evidenced findings supportive 
of the spinal vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent 
pain. Documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as 
being medically necessary and/or reasonable at this time. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an at-home COVID-19 test provided on January 12, 2022. 
 
You asked the Plan to pay for an at-home COVID-19 test. You say that a representative of the Plan told you 
that an at-home COVID-19 test would be covered for you. The Plan denied your request. The Plan says an at-
home COVID-19 test was not a covered benefit at the time of purchase. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and an at-home 
COVID-19 test is an OTC item. The Plan has instituted an exception for at-home COVID-19 tests that became 
effective February 1, 2022. The date of service in this case is prior to the exception's effective period. 
Therefore, we decided that the Plan does not have to pay for an at-home COVID-19 test provided on January 
12, 2022.  
 
Your complaint about receiving incomplete or ambiguous information about your benefits from a 
representative of the Plan is not a valid appeal 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: Transportation
Decision: Favorable

 
We decided that the Plan has to pay more for procedure code A0427 billed for date of service January 19, 
2022. 
 
You asked the Plan to pay more for procedure code A0427. You say that this claim was underpaid. The Plan 
denied your request. The Plan says that the claim was paid correctly, taking into account the patient's 
deductible. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the case file that the Plan submitted to us had virtually no 
information in it.  It contained no claim forms, no screen prints of electronic claims, no Remittance Advices or 
Explanations of Benefits.  It also did not contain any documents or proof of how the member's outstanding 
deductible balance was calculated.  All of this documentation is within the Plan's control, and they failed to 
provide it.  This documentation is crucial to determine the appropriate amount of payment for this claim.  The 
burden is on the Plan to show why its denial is appropriate, and they have failed to do so here. Therefore, we 
decided that the Plan has to pay more for procedure code A0427 billed for date of service January 19, 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 user-adjustable heel height feature (L5990). 
 
You asked the Plan to pre-approve a user-adjustable heel height feature. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a user-adjustable heel height feature (L5990) will 
be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The item at issue is not considered medically necessary. Based on 
this information, we decided that Medicare rules for coverage of a user-adjustable heel height feature have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a user-adjustable heel height 
feature (L5990).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested procedure fills a 
treatment gap for those patients that do not receive adequate relief from traditional conservative methods and 
don't have instability to indicate fusion is the appropriate treatment. You say that you have tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says the request is not medically 
necessary because there is little evidence in the medical literature to suggest that this is an appropriate 
procedure for the enrollee's back pain. 
 
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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided on 
November 30, 2021. 
 
You asked the Plan to pay for the continuous glucose monitor (CGM) supplies. You say that you disagree with 
the plan's denial. The Plan denied your request. The Plan says the documentation did not contain a valid 
physician order. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain a valid physician order for the supplies provided in this case. Review of the file 
shows that the physician order is illegible. The physician order must include the beneficiarys name, the item of 
DME ordered, the NPI of the prescribing physician/practitioner, the signature of the prescribing 
physician/practitioner, and the date of the order. In addition, the Plan reached out to the physician whose order 
was included in the documentation and has confirmed that this order did not come from this physician. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies 
provided on November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided on October 6, 2021. 
 
You asked the Plan to pay for acupuncture. You say that the acupuncture is medically necessary. The Plan 
denied your request. The Plan says a licensed acupuncturist is a non-covered provider type and the provider is 
not supervised by any physician, physician assistant, nurse practitioner or a clinical nurse specialist. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.   We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, a licensed acupuncturist is a non-covered provider 
type and the provider is not supervised by any physician, physician assistant, nurse practitioner or a clinical 
nurse specialist. Therefore, we decided that the Plan does not have to pay for acupuncture provided on October 
6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional x-ray services provided to the enrollee on August 
31, 2021. 
 
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 records submitted do not indicate that two separate services were performed or supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of code 71046 is "Radiologic examination, chest; 2 views." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the records reveal that only one exam 
of a two-view chest x-ray was done on the date of service. 
 
We looked at this coder'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 pay for additional x-ray services provided to the enrollee on August 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81442, 81411, 81439, 
81410, 81161, 81286, 81413, and 81414) provided on October 1, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Our records indicate a NCCI PTP edit exists 
between 81413, 81414 and 81439. This PTP edit has a modifier indicator of 0, which indicates there are no 
modifiers that are allowed with this PTP code pair. Furthermore, the denial of the cardiovascular screening/risk 
assessment panel is administratively upheld for not meeting Medicare coverage criteria. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (CPT code(s): 81442, 81411, 81439, 81410, 
81161, 81286, 81413, and 81414) provided on October 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Recco Euro Scooter. 
 
You asked the Plan to pre-approve Recco Euro Scooter. You say that you feel this would be a good fit to give 
you a better quality of life. The Plan denied your request. The Plan says you do not meet criteria for the 
requested item. 
 
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 you do not have a mobility deficit that impairs your participation in MRADLs. 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 Recco Euro Scooter.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for additional x-ray services provided to the enrollee on September 24, 
2021. 
 
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 that the records submitted do not indicate that two separate services were performed or 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 74018 is "Radiologic examination, abdomen; 1 view." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found there were two separate one view 
abdomen films done on 9/24/21. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
additional x-ray services provided to the enrollee on September 24, 2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on December 8, 2021. 
 
You asked the Plan to reimburse you for hearing aids. You say that you thought you could use an  
out-of-network provider since you have used this provider for over 20 years. The Plan denied your request. The 
Plan says the member has no coverage for hearing aids if they are not received from the Plan's hearing 
provider. 
 
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 the Plans hearing provider. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not ordered through the 
Plans hearing provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids 
have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids 
provided on December 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that up until this point, regular PT has allowed 
the enrollee to keep making gains in her strength and balance regardless of home exercise program completion. 
You also say that reducing or denying the enrollee's ability to participate in intermittent PT will likely lead to 
further deconditioning. The Plan denied your request. The Plan says continued PT is 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 PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy generally is not accepted as specific 
and effective therapy for the patients condition beyond what was approved by the health plan. The patient has 
had prior therapy and the documentation does not reveal that the patient requires the unique skills of a 
professional therapist to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. Our reviewer also found that the 
requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of 
a qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's 
current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 12 additional physical therapy (PT) visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (52353) provided on January 25, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is 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 CPT code. In this case, we have confirmed that code 52353 is a column II code to column I code 52356. 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 the services (52353) provided on January 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vehicle lift. 
 
You asked the Plan to pre-approve a vehicle lift. You say that your scooter is too heavy to lift without 
assistance. The Plan denied your request. The Plan says rules for coverage for durable medical equipment have 
not been met. 
 
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 vehicle lift.