Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient mental health services to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve outpatient mental health services. You say that you're not in a good place 
and need to be seen sooner than your in-network provider can get you in. The Plan denied your request. The 
Plan says there are providers in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
outpatient mental health services to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
December 30, 2021, to January 18, 2022. 
 
You asked the Plan to pay for home health services. 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. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the RAP 
claim was not submitted. Therefore, we decided that the Plan does not have to pay for the home health services 
provided to the enrollee from December 30, 2021, to 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 March 29, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that you are requesting to waive the no prior 
precertification authorization denial based on medical necessity. The Plan denied your request. The Plan says 
the out-of-network services were not authorized. 
 
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 March 29, 2022, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary to bring back full 
function for the enrollee. The Plan denied your request. The Plan says there is no documentation that the 
enrollee as had at least 50% sustained improvement in pain and function for at least 3 months. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the previous injection was less than six weeks ago. The review has determined that the enrollee does 
not meet the coverage indications for the repeat injection. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 97530-GO-CO-KX (4 units) billed for date of service 
October 5, 2021. 
 
You asked the Plan to pay for code 97530. You say that you have provided records to support payment. The 
Plan denied your request. The Plan says 97530 is not the appropriate code for the service billed.  You should 
have billed code G0158 instead. 
 
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 97530 is therapeutic activities, using dynamic activities 
one on one patient contact by the provider to improve functional performance (real-life movements), each 15 
minutes.  However, the medical records indicate that the services on October 5, 2021, were provided by an 
occupational therapy assistant in a home health setting.  Code G0158 is to be billed for services performed by a 
qualified occupational therapist assistant in the home health or hospice setting.  As a result, the code you billed 
for this service does not accurately reflect the service provided. Based on this information, we decided that Medicare rules for coverage of code 97530 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 97530-GO-CO-KX (4 units) billed for date of service October 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation. 
 
You asked the Plan to pre-approve routine transportation. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve routine transportation.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77062 billed for date of service May 19, 
2022. 
 
You asked the Plan to pay for procedure code 77062. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
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 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 77062 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77062 billed for date of service May 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient services provided on March 30, 
2022 to April 1, 2022. 
 
You asked the Plan to waive the copayment for inpatient services. You say that you were scheduled to have 
day surgery. You say that during the procedure your lung was punctured and then collapsed which led to your 
admission. You say that you feel you should not be liable for the inpatient stay. 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 $390 
copayment each time you are admitted to an acute care hospital, you pay $390 per day for days 1-5 and $0 after 
day 5. This applies to all admissions, including transfer from another facility such as an acute rehabilitation or 
skilled nursing.  
 You have been asked to pay a total of $780 ($390 x 2 days = $780). Inpatient services fall within the Inpatient 
Hospital 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 inpatient services provided 
on March 30, 2022 to April 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is alert and are willing to participate in 
an intensive rehabilitation program. The Plan denied your request. The Plan says the admission is not medically 
necessary, and the enrollee can recieve care in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for congestive heart failure and was discharged home on 9/15/22. There is ongoing weakness. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Detect test (0012M) provided May 16, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with this decision and 
appreciate prompt review of this information and authorization of coverage for the Cxbladder Detect test. The 
Plan denied your request. The Plan says under Medicare guidelines, this request is not a covered benefit. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the Cxbladder Detect test (0012M) provided May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography scan (D0367), and bone 
replacement graft (D7953) provided from May 12, 2022, through May 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for the services. The 
Plan denied your request. The Plan says the services at issue are not covered 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 a cone 
beam computed tomography scan (D0367), and bone replacement graft (D7953) provided from May 12, 2022, 
through May 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical connection between the wheelchair 
controller and two or more motors (E2311), an expandable controller (E2377) and a harness (E2313). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you are completely reliant on this 
complex power wheelchair equipped with power tilt, recline and elevating leg rests to meet your repositioning 
and pressure management needs throughout the day. Due to your recent weight gain the current base is no 
longer meeting your mobility needs and a heavy-duty power base is medically necessary to support your 
weight. The Plan denied your request. The Plan says the requested wheelchair accessories cannot be covered. 
Although there are three requested power options, there is not a medical need to control these power options 
through the joystick. 
 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.  
 
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 wheelchair accessories. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found you have good function in upper 
extremities and have sufficient function to operate standard switches for the multiple power drives. You are 
modified independent for transfers, standing, meal prep, and toileting. The single point control 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 wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electrical connection between the wheelchair controller and two or more 
motors (E2311), an expandable controller (E2377) and a harness (E2313).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray and oral evaluation (D0210, D0150) 
provided on July 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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. 
 
 
  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 September 1, 2020. Therefore, 
we decided that the Plan does not have to pay for an intraoral x-ray and oral evaluation (D0210, D0150) 
provided on July 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair accessory, quick release axle (K0108). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the requested wheelchair accessory is not a covered benefit with your plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair accessory, quick release axle (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair accessory, electronic connection 
between wheelchair controller and two or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve a power wheelchair accessory. You say that the enrollee requires an 
appropriately configured G2 PWC w/power tilt for home mobility, repositioning, pressure relief & participation 
in MRADL. The Plan denied your request. The Plan says because the enrollee is able to control power with its 
own switch, there is no need to control the power option through the joystick. 
 
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. Specifically, the 
enrollee can control power on its own switch, there is no medical need for power through the joystick. 
Therefore, we decided that the Plan does not have to pre-approve a power wheelchair accessory, electronic 
connection between wheelchair controller and two or more power seating system motors (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reduced shear recline stroller handle and transport 
brackets (K0108). 
 
 
 
 
 You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial. You also 
say your mission is to provide mobility to patients who otherwise would be unable to function in a normal 
environment or would be confined to a bed without your custom equipment. The Plan denied your request. The 
Plan says a push handle that facilitates caregiving to keep the enrollee in recline while pushing the patient on 
ramps, inclined, or across thresholds is for the convenience of the caregiver while pushing the enrollee 
primarily outdoors. Transport brackets are used for securing an unoccupied wheelchair in a motor vehicle. 
Durable medical equipment like wheelchairs is primary for assisting an enrollee in customary locations in the 
home. There must be an in-home need. 
 
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 reduced shear recline stroller handle and transport brackets 
(K0108).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 26 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that the enrollee still needs contact guard assistance 
with standing supported exercises to prevent falls. The Plan denied your request. The Plan says the remaining 
26 physical therapy visits are 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 therapy 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 that the enrollee has had prior therapy and the documentation does not 
reveal that the enrollee's high function level requires the unique skills of a professional therapist. The enrollee 
has been trained in a home exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 26 physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve dental services to be provided by an oral surgeon. You say that you would 
like the Plan to reconsider their denial. The Plan denied your request. The Plan says dental services are only 
covered when provided by a general dentist. 
 
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 when provided by an oral surgeon. Therefore, we decided that the Plan 
does not have to pre-approve dental services to be provided by an oral surgeon.