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

 
We decided that the Plan does not have to pre-approve a NuMotion Jazzy Elite Elite 14 2S-C Group 2 power 
wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says there was no documented face-to-face encounter with the provider within the past 
six months. 
 
The Plan follows Medicare rules. Medicare rules say that the standard written prior to delivery (WOPD) for the 
wheelchair may only be written after the completion of the face-to-face encounter requirements. 
 
The records do not contain evidence of a valid face-to-face encounter prior to requesting the wheelchair. Based 
on this information, we decided that Medicare rules for coverage of the wheelchair have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a NuMotion Jazzy Elite Elite 14 2S-C Group 
2 power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new pair of eyeglasses. 
 You asked the Plan to pre-approve new eyeglasses. You say that you are having issues with your current 
eyeglasses and would like to use your benefit to replace them. The Plan denied your request. The Plan says you 
previously used your benefit on October 19, 2021, and therefore are not eligible for new eyewear through your 
Plan until October 19, 2022. 
 
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 once per rolling calendar year. 
 
We looked at the file and the Plan's rules. The record shows that you last used your vision benefit for eyewear 
on October 19, 2021. This means that your benefit is currently exhausted. Based on this information, we 
decided that the Plan's rules for coverage of new eyeglasses have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a new pair of eyeglasses.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on November 26, 
2021. 
 
You asked the Plan to pay for the services. You say that  The Plan denied your request. The Plan says the 
denied codes remain not 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 the denied codes is: 
 
CPT 22846: 
 
Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure) 
 
CPT 20930: 
 
Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in 
addition to code for primary procedure) 
 
CPT 69990: 
 
Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for 
primary procedure) 
 
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 for CPT 22845. Our reviewer says that the services at issue in this case 
were not supported by the medical records. Our reviewer found the operative report does not describe or verify 
anterior instrumentation in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Our reviewer founded that CPT 22846 is not 
supported. CPT 20930 has a status indicator of B, which means that it cannot be reported separately, and is 
always bundled into payment for other services. CPT 69990 should not be reported separately from CPT 
22551. Additionally,  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 November 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 sensor (K0553). 
 
You asked the Plan to pre-approve the Dexcom G6 sensor. The Plan denied your request. The Plan says you do 
not meet the criteria for coverage. 
 
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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the Dexcom G6 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G6 sensor (K0553).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 19, 
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 provider did not bill as required by Medicare coding regulations. 
 
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 80076 
is a column II code to column I code 80053 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for laboratory services provided to the enrollee on January 19, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for esophagogastroduodenoscopy (EGD) provided to the 
enrollee on January 21, 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 billed service was denied because it did not include the appropriate primary, first-listed or 
principal diagnosis code. 
 
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 43235 is "Esophagogastroduodenoscopy, flexible, 
transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate 
procedure)." 
 
We find that CPT code 43235 is not supported in the medical record. Specifically, this code did not have an 
appropriate primary diagnosis code billed with it on the claim. 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 esophagogastroduodenoscopy (EGD) provided to the enrollee on January 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 3, 
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 Medicare denies coverage when a laboratory assays two or more genes in parallel. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 laboratory services provided to the enrollee on September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerecis Omega 3 (15271, Q4158). 
 
You asked the Plan to pre-approve Kerecis Omega 3. You say that the requested treatment is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 Kerecis Omega 3. Our reviewer says 
that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Kerecis Omega 3 may be needed when there are diabetic or Venous insufficiency ulcers. In this 
case, notes from the provider show that the enrollee has a pressure ulcer on the sacral region. The notes did not 
show the enrollee has diabetic ulcers or Venous insufficiency ulcers. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kerecis Omega 3 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Kerecis Omega 3 (15271, Q4158).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional routine transportation trips. 
 
You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your 
request. The Plan says additional transportation trips are not covered. 
 
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.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement endoskeletal ankle foot system, 
microprocessor-controlled feature, dorsiflexion and/or plantar flexion control, includes power source (L5973). 
 You asked the Plan to pre-approve the K3 foot. You say that the enrollee medically requires and objectively 
exhibits improvements in gait pattern and overall enablement through use of a microprocessor-controlled 
foot/ankle component. The Plan denied your request. The Plan says Medicare does not cover replacements for 
items that are still under warranty. The current foot is under 36 months old and still under warranty. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the K3 foot have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
replacement endoskeletal ankle foot system, microprocessor-controlled feature, dorsiflexion and/or plantar 
flexion control, includes power source (L5973).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 2 mastectomy bras (L8000). 
 
You asked the Plan to pre-approve an additional 2 mastectomy bras (L8000). You say that 4 bras per year does 
not work for you. You say that it is difficult to wash them by hand and believe the additional 2 bras would be 
beneficial for you. The Plan denied your request. The Plan says we cover 4 mastectomy bras per year. 
 
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, the Plan's contract, and Medicare rules. The file shows you are requesting 2 additional 
mastectomy bras for the purpose of convenience. The Plan's contract shows that they only cover 4 mastectomy 
bras per year. The file shows that you have ordered your 4 bras approved by the Plan. Therefore, we decided 
that the Plan does not have to pre-approve an additional 2 mastectomy bras (L8000).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx testing provided on February 2, 2022. 
 
You asked the Plan to pay for the testing services. You say that there are no similar tests available to treat 
cutaneous melanoma. The Plan denied your request. The Plan says the test is not recommended as a part of the 
risk-stratification process. 
 
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 pay for the testing services. Our physician reviewer 
found that the use of molecular tests such as DecisionDx-SCC are not considered a standard of care for 
determining treatment of squamous cell carcinoma. Its use is not supported by the NCCN Guidelines or the 
medical literature. Therefore, the service was 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 the testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the DecisionDx testing provided on February 2, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Cardiac Rehab provided on September 1, 2021 to September 
27, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Cardiac Rehab. 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 Cardiac Rehab provided on September 1, 2021 to 
September 27, 2021 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
January 4, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were advised to go only for a 
COVID-19 test, which was negative. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
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 $90 
copayment for each emergency room visit.  
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency Care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an emergency room (ER) visit 
provided on January 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee sleeve (A4467). 
 
You asked the Plan to pre-approve a knee sleeve. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says a knee sleeve described by code A4467 is not covered by 
Medicare or the Plan. 
 
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. Medicare specifically excludes coverage of knee sleeves coded as 
A4467. Therefore, we decided that the Plan does not have to pre-approve a knee sleeve (A4467).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for home health skilled nursing facility (SNF) services provided to the 
enrollee from November 10, 2021, to November 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 payment is not allowed for this claim because the Federal Information Processing Standards 
(FIPS) code is missing or invalid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
The plan has not submitted an accurate and appropriate denial for these services. The claim form submitted 
with the appeal has a FIPS code of 36009, which correlates to the correct city, county, and state for where the 
services were rendered. 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 home health skilled nursing facility (SNF) 
services provided to the enrollee from November 10, 2021, to November 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
January 8, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were misdirected to the ER and 
not allowed to leave. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 $90 
copayment for each emergency room visit.  
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency Care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an emergency room (ER) visit 
provided on January 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
thorax provided on January 18, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you were never charged for this 
service before. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 $170 
copayment for radiological diagnostic services, such as CT scans.  
 
You have been asked to pay $134.13, which is less than the $170 copayment for the CT scan. The CT scan falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a computed tomography (CT) scan of the thorax provided on January 
18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that at the time of service, an authorization was not 
obtained, and you believe the patient was admitted for medical necessity. The Plan denied your request. The 
Plan says the rendering provider is a non-participating provider and there is no referring provider involved in 
these services. The Plan also says that they did not authorize any services for this provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on February 10, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 30, 
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 if a laboratory assays two or more genes in a patient in parallel, then those two or more genes 
will be considered part of the same panel. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 laboratory services provided to the enrollee on August 30, 2021.