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

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options (E0955, E1007, E1012, E1028, E2300, E2311, E2313, E2359, E2377, E2607, E2620, K0861). 
 You asked the Plan to pre-approve the group 3 power wheelchair with multiple power options. You say that 
this type of wheelchair is medically necessary. The Plan denied your request. The Plan says coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with multiple power 
options is covered when medically necessary. 
 
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 group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested wheelchair is not medically necessary. Our 
physician reviewer found the enrollee is not at high risk for skin breakdown, does not use a catheter, nor does 
he have significant spasticity. The power seat elevation is considered not medically necessary. The enrollee 
does not require an expandable controller as he has adequate strength to manage standard switch on a power 
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 group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple 
power options (E0955, E1007, E1012, E1028, E2300, E2311, E2313, E2359, E2377, E2607, E2620, K0861).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 17, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit an office visit. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the enrollee must receive care from a network 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 an office visit 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for an office visit  provided on August 17, 2022, by an OON 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary to increase 
strength, balance, endurance, and overall functional mobility. The Plan denied your request. The Plan says 
based on Medicare guidelines, the IRF services you are requesting do not meet the requirements for approval. 
 
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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met at a lower level of care. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the annual depression screening (G0444) provided on August 2, 2022. 
 
You asked the Plan to pay for the annual depression screening. You say that you received a bill saying this 
service was not covered. You also say that you found on the internet that this service is allowed once per year. 
The Plan denied your request. The Plan says that the maximum amount has been covered for this service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the file does not support that this service has been paid previously. 
Therefore, we decided that the Plan has to pay for the annual depression screening (G0444) provided on 
August 2, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 19, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the medical records show that these services 
were provided, so the claim was denied in error. The Plan denied your request. The Plan says the number of 
units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with a LT modifier and one line 
item of this code with the RT modifier instead of billing one line item of this code with the bilateral modifier as 
is required. Based on this information, we decided that Medicare rules for coverage of procedure code 76641 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed 
for date of service October 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Transcutaneous Electrical Nerve Stimulators (TENS) 
device (E0730) 
 
You asked the Plan to pre-approve a TENS device. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is not covered for chronic low back pain. 
 
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 a TENS device have not been met. Specifically, the records submitted indicate this device has been 
ordered to treat chronic low back pain which is not a covered use. 
 
 
  
 
 Therefore, we decided that the Plan does not have to pre-approve a Transcutaneous Electrical Nerve 
Stimulators (TENS) device (E0730)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve dental services. You say that you would like the requested dentist approved. 
The Plan denied your request. The Plan says there are in-network providers available to provide the required 
services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
dental services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148). 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the enrollee will need an updated 
lumbar MRI to prepare for their visit. You also say the enrollee has completed physical therapy and failed 
conservative care. The Plan denied your request. The Plan says that the requested imaging does not appear to 
be medically reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI of the lumbar spine. Our 
physician reviewer found since the enrollee's prior MRI, which was 9 months ago, they have had 2 epidural 
steroid injections and have failed physical therapy. Our reviewer also found that the requested MRI is for a pre-
surgical visit and since their previous exam was 9 months ago and they have had 2 procedures since, the 
request for a repeat MRI prior to surgical evaluation is reasonable and should be approved. 
 
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 MRI of the lumbar spine have been met. Therefore, we decided that the Plan 
has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).  
 
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: 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. The Plan denied your request. The Plan says the enrollee does not 
have complex therapy needs that require close supervision by a physician specializing in rehabilitation 
Medicine. 
 
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 there is not a reasonable expectation that the 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675), and sleeve 
(E0673), provided on July 28, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. 
The Plan denied your request. The Plan says these items are not covered for preventions of venous 
thromboembolism nor for treatment of peripheral artery disease during or after surgery. 
 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675), and sleeve (E0673), provided on July 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for functional medicine services provided on 
March 24, 2022. 
 
You asked the Plan to reimburse you for the functional medicine services. You say that the Plan paid for a visit 
with this provider for date of services January 4, 2022. The Plan denied your request. The Plan says the 
member was reimbursed for a prior claim in error The Plan is not going to request money back but is now 
adhering to the Evidence of Coverage Booklet rules. The Plan verified with the providers office that they do 
not accept Medicare or any insurance. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. Medicare says no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for functional medicine services 
provided on March 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ocrevus. 
 
You asked the Plan to pre-approve Ocrevus. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Ocrevus. Our reviewer says that the 
requested drug does not meet step therapy criteria. Our physician reviewer found the enrollee has relapsing 
remitting multiple sclerosis. The documentation does not support that the enrollee has tried and failed 
Kesimpta. The documentation does not support that Kesimpta would likely be less effective and/or likely have 
adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ocrevus have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ocrevus.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will benefit from the 
LTACH in an effort to regain maximum prior level of functioning and a continued multi-disciplinary approach 
to care. The Plan denied your request. The Plan says the request for LTACH admission does not meet criteria 
for coverage. 
 
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 there is no evidence that the enrollee requires services that are not currently available 
at the current acute care hospital. As LTACHs and acute care hospitals 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 
acute care hospital until such time no acute services are required. The enrollee can then be transferred or 
discharged to a lower level of care for any ongoing long term care 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Lumbar-sacral orthosis (LSO) (L0650), provide on 
September 27, 2022. 
 
You asked the Plan to pay for a LSO. You say that the items was medically necessary. The Plan denied your 
request. The Plan says there was no mention of a discussion with the patient regarding ordering devices to 
handle back pain in the medical records. In addition, the service date is well beyond the 6 months face-to-face 
encounter requirements. 
 
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 or relevant medical records which support medical 
necessity for the supplies provided in this case. there was no mention of a discussion with the patient regarding ordering devices to handle back pain in the medical records. In addition, the service date is well beyond the 6 
months face-to-face encounter requirements. 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 a 
Lumbar-sacral orthosis (LSO) (L0650), provide on September 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composites (D2392 and D2393) and intraoral 
imaging (D0220 and D0230) provided on August 12, 2022. 
 
You asked the Plan to pay for resin-based composites and intraoral imaging. You say that you told the dentist 
to no perform any services that would not be covered. The Plan denied your request. The Plan says the denied 
services 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 resin-
based composites (D2392 and D2393) and intraoral imaging (D0220 and D0230) provided on August 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found you have osteoporosis. The documentation does not support that you have tried and failed Reclast 
(Zoledronic Acid). The documentation does not support that Reclast would likely be less effective and/or likely 
have adverse effects. Therefore, you do not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86078 billed for date of service May 25, 
2022. 
 
You asked the Plan to pay for procedure code 86078. You say that medical records show medical necessity. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 86078 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 86078 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 86078 billed for date of service May 25, 2022.