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

 
We decided that the Plan has to pre-approve an advanced foot. 
 
You asked the Plan to pre-approve an advanced foot. You say that the services are necessary. The Plan denied 
your request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are covered when specific 
criteria are met. 
 
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 an advanced foot. Our reviewer says 
that the services are medically necessary. Our physician reviewer found both the prosthetic evaluation and 
clinical progress note indicate that you have the potential to be a K3 level ambulator. Your current prothesis 
requires replacement since it limits is ability to ambulate and you must use a walker to offload your residual 
limb due to the prosthesis not fitting properly, causing a wound on your residual limb. You are noted to have an 
intact contralateral limb and can ambulate without your prosthesis with a walker for 30 feet as well as stand in 
the parallel bars for over one minute and hop for several feet. You do have the strength to meet the 
requirements to be a K3 level ambulator. Therefore, the Espirit K3 level prosthetic foot is 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 an advanced foot have been met. Therefore, we decided that the Plan has to pre-
approve an advanced foot.  
 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 continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve a CGM and related supplies. You say that the requested items are a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage for the requested items 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 CGM and 
related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a CGM 
and related supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a wheelchair provided from July 22, 2021, 
to February 22, 2022. 
 
You asked the Plan to waive the coinsurance for a wheelchair. You say that you should not be responsible to 
pay this. 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 $20% of 
the cost for all other Medicare-covered durable medical equipment items.  
 
 
 
 
 
 You have been asked to pay $52.53 for a wheelchair. This item/service falls within the durable medical 
equipment (DME) and related 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 coinsurance 
for a wheelchair provided from July 22, 2021, to February 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Bioness Go Thigh Plus functional electrical 
stimulation system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show a non-neurological reason for weakness or difficulty walking 
due to a spinal cord injury. 
 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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that detailed documentation is not evident concerning a spinal cord injury. The guidelines do not support 
the use of neuromuscular electrical stimulation for walking without a known spinal cord injury. Therefore, the 
enrollee does not meet the criteria for this request.  
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Bioness Go Thigh Plus functional electrical stimulation system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is currently undergoing treatment at an ACH for lower extremity 
infection. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that 
are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH.  The enrollee can remain at the current ACH until such 
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for 
any ongoing LTC 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair and accessories. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request exceeds the enrollee's medical needs, and is not reasonable and necessary, 
per the Medicare criteria. 
 
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 the items. Our reviewer says that the 
requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that based on the 
medical records provided, there is no documentation in the clinical records from treating physician that you can 
safely operate a power mobility device. It is unclear if your mobility deficit cannot be helped by the use of a 
manual wheelchair.  
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a group 2 power wheelchair and accessories.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on April 26, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the services have not been met. Therefore, we decided that 
the Plan does not have to pay for the services provided on April 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0239U) provided on April 14, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 CPT code 0239U is not supported in the medical record. Specifically, the date the specimen was 
collected (April 7, 2022) does not match the date of service billed. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for genetic testing (0239U) provided on April 14, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the inpatient hospital care services received June 5, 
2022, to June 7, 2022 minus any cost share requirement. 
 
You asked the Plan to hold you harmless for the inpatient hospital care services. You say that your doctor felt it 
was important to watch you because your blood pressure was so high. The Plan denied your request. The Plan 
says that the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Before discharging an enrollee from an inpatient hospital level of care, 
Medicare rules say that the Plan must obtain concurrence from the physician who is responsible for the 
enrollee's inpatient care. 
 
In this case, the record did not show that the physician responsible for the enrollee's inpatient care concurs with 
not having the enrollee be inpatient. In addition, you should not be held responsible for the billing issue of the 
provider. Therefore, we decided that the Plan has to hold you harmless for the inpatient hospital care services 
received June 5, 2022, to June 7, 2022 minus any cost share requirement.  
 
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 group 3 power wheelchair with accessories. 
 
You asked the Plan to pre-approve the wheelchair and accessories. The Plan denied your request. The Plan says 
this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. As the wheelchair is not covered, the requested accessories are also 
not covered. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with 
accessories.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport (A0429RW) provided on March 5, 2022. 
 You asked the Plan to pay for the ambulance service. You say that you are an ET3 provider (emergency triage, 
treat, and transport). You say that the claim was billed correctly. You also say that this should be paid. The 
Plan denied your request. The Plan says the claim processed correctly. 
 
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 March 5, 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 service, basic life support, 
emergency transport (A0429RW) provided on March 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 29, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim was billed 
incorrectly. 
 The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A57526. Based on this information, we decided that Medicare rules for coverage of 
the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service June 6, 2022. 
 
You asked the Plan to pay for procedure code 99233. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the code billed 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 99233 
is a column II code to column I code 99221 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 procedure code 99233 billed for date of service June 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture. 
 
You asked the Plan to pre-approve the dental services. You say that your previous denture is very small and 
easy to swallow. 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 25, 2020. Therefore, 
we decided that the Plan does not have to pre-approve maxillary partial denture.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on March 30, 2022. 
 
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan 
denied your request. The Plan says the place of service on the CMS-1500 form line 24B must reflect the 
location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory 
specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim 
history indicates that the specimen was obtained in an office setting POS 11.  Also, the laboratory results 
submitted indicate the specimen was collected on March 30, 2022, and received by the lab on March 31, 2022; 
therefore, the billed code cannot be verified.  It is noted multiple attempts were made to obtain additional 
information from the provider 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes.  
 In this case, this claim cannot be paid as billed due to an issue with the POS code. Based on this information, 
we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that 
the Plan does not have to pay for lab services provided to the enrollee on March 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (Urine PCR Test) provided to the enrollee on 
February 1, 2022. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says the Medicare guidelines state that the standard of care for the 
evaluation of urinary incontinence is urinalysis with urine culture and sensitivity. The testing provided is 
considered unproven and not medically necessary. The Health Plan feels that the denial of Urine PCR Panel 
was appropriate given the clinical scenario and the guidance presented. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, this testing was not demonstrated to be 
medically necessary based on Medicare guidelines. Therefore, we decided that the Plan does not have to pay 
for lab services (Urine PCR Test) provided to the enrollee on February 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81455) billed for date of service April 17, 
2022. 
 
You asked the Plan to pay for genetic testing. You say that the service at issue was billed correctly. The Plan 
denied your request. The Plan says rules for payment have not been met because the claim at issue was billed 
with the incorrect DOS. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the 
specimen was collected. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Specifically, the available documentation indicates that the 
specimen was collected on April 5, 2022. The case record does not support an exception to the rules. Therefore, 
we decided that the Plan does not have to pay for genetic testing (81455) billed for date of service April 17, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) provided from 
December 11, 2021, to December 29, 2021. 
 
You asked the Plan to pay for the PCD. The Plan denied your request. The Plan says payment is included under 
the facility claim. 
 
The Plan must follow Medicare rules. Medicare rules say that All items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. This 
provision applies to all hospitals, regardless of whether they are subject to PPS.  
 
We looked at the file and Medicare rules. Payment for the PCD would be included in the payment to the 
facility in this case. Separate payment cannot be made. Based on this information, we decided that Medicare 
rules for coverage of the PCD have not been met. Therefore, we decided that the Plan does not have to pay for 
the pneumatic compression device (PCD) provided from December 11, 2021, to December 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis, 51 or greater genes 
(81455) provided April 12, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that this letter and the attached documents 
support the medical necessity of the tests requested. The Plan denied your request. The Plan says the test was 
billed with diagnosis C86.4 Blastic NK-Cell Lymphoma, which is not listed on the LCD Article A56867 as 
coverable code that supports medical necessity.  
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. Per Local Coverage Article A56867, any diagnosis code not listed 
does not support medical necessity. Based on this information, we decided that Medicare rules for coverage of 
the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay for targeted 
genomic sequence analysis, 51 or greater genes (81455) provided April 12, 2022.