Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 9, 2022, to 
February 4, 2022. 
 
You asked the Plan to pay for the home health services. You say that there is proof of timely filing for the 
notice of admission claim. The Plan denied your request. The Plan says the claim has not been billed with the 
correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment have not been met. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from January 9, 2022, to February 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with power tilt option. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has lower extremity muscle 
weakness. The Plan denied your request. The Plan says the request exceeds the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchairs are only covered under certain 
medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has chronic obstructive pulmonary disease (COPD) and post-polio syndrome. 
The enrollee does not require power recline or tilt as he does not have the conditions, high risk for skin 
breakdown, reliance on a catheter or ventilator which make power tilt or recline medically necessary. 
Therefore, the requested wheelchair 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a group 3 power wheelchair with power tilt option.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), first intraoral 
periapical x-ray (D0220), two additional intraoral periapical x-rays (D0230 x2), prophylaxis (D1110), and 
palliative (emergency) treatment of dental pain (D9110) provided on August 1, 2022, and August 2, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the Plan should cover 50% of the cost for 
the services provided on August 1, 2022, and Medicare is supposed to pay up to $1,500 for approved services. 
You also say that you would like the Plan to include your share in the $1,500, because you feel like you were 
misled. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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. 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the periodic oral evaluation (D0120), first 
intraoral periapical x-ray (D0220), two additional intraoral periapical x-rays (D0230 x2), prophylaxis (D1110), 
and palliative (emergency) treatment of dental pain (D9110) provided on August 1, 2022, and August 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pembrolizumab (Keytruda). 
 
You asked the Plan to pre-approve Keytruda. You say that additional treatment will prevent complications and 
progression of the disease. The Plan denied your request. The Plan says there is a lack of indication for 
Keytruda for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our physician reviewer 
found that the enrollee has metastatic undifferentiated pleomorphic sarcoma. Keytruda is not compendia 
supported for undifferentiated pleomorphic sarcoma. There is literature support only in abstract form. The 
requested use is considered investigational/experimental. The documentation does not support that the 
requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve pembrolizumab (Keytruda).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist hand orthosis (L3916), provided on July 28, 2022. 
 
You asked the Plan to pay for the wrist hand orthosis. You say that the items are medically necessary. The Plan 
denied your request. The Plan says the documentation submitted did not sufficiently support the billed supply 
code. 
 
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. The documentation submitted does not indicate the prescribing 
physician ordered the items and the medical records do not indicate the item was needed. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided 
that the Plan does not have to pay for the wrist hand orthosis (L3916), provided on July 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a filling (D2332) provided on July 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that the service was necessary. 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 October 27, 2021. 
Therefore, we decided that the Plan does not have to pay for a filling (D2332) provided on July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist visits provided on February 17, 
2022, to September 21, 2022. 
 
You asked the Plan to waive the copayment for specialist visits. You say that you are disputing the share cost. 
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 
copayment for outpatient mental health care. There were 7 visits, resulting in a total copayment amount of 
$140. 
 
You have been asked to pay $20 copayment for each specialist visit. This item/service falls within the 
outpatient mental health 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 specialist 
visits provided on February 17, 2022, to September 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 12, 2022, to 
April 10, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the claim has not been 
billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 12, 2022, to April 
10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure (D1999) provided on May 26, 
2022. 
 
You asked the Plan to pay for the preventive procedure. You say that you would like to appeal this service. The 
Plan denied your request. The Plan says this service is not covered. 
 
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 the preventive procedure (D1999) provided on 
May 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0861), a power seat 
elevation system (E2300) and an expandable controller (E2377). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee has a 
fractured left femur and underwent surgery 9/23/22. The enrollee has an intramedullary rod in place and is 
nearly healed. There are no grounds to deny him a standing frame as he has no restrictions regarding his left 
lower extremity. The Plan denied your request. The Plan says the request for PWC was denied as you sustained 
a left distal femoral shaft fracture and underwent an open reduction internal fixation. 
 
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 a power wheelchair and accessories. 
Our reviewer says that the service is not medically reasonable or necessary. Our physician reviewer found the 
enrollee is non-ambulatory and cannot use a cane or walker for mobility given his T7 level spinal cord injury. 
The enrollee is currently using a power wheelchair with a power standing system. It appears that the enrollee 
cannot propel a manual wheelchair for mobility or operate a power scooter due to impaired sitting balance and 
impaired ability to transfer. He requires a power wheelchair for mobility and accomplishing his daily activities. 
Given his history of skin breakdown, it appears that he requires power tilt and recline for pressure relief as well 
as power elevating leg rests given his lower extremity spasticity. However, the clinical documentation is 
insufficient regarding the enrollee's ability to safely use the power standing feature. He is noted to be weight 
bearing as tolerated per the clinical documentation, but the power mobility evaluation indicates he has not been 
able to use the power standing feature on his existing power wheelchair and was encouraged to participate in a 
standing program with physical therapy. There is a lack of objective documentation that he can safely tolerate 
the use of the power standing system or has successfully participated in a standing program. Therefore, the 
power wheelchair with a power standing feature cannot be considered 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 a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 power wheelchair (K0861), a power seat elevation system 
(E2300) and an expandable controller (E2377).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 12, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says Medicare does not 
separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 12, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99203). 
 
You asked the Plan to pre-approve an office visit. You say that you are still having pain in your back. You also 
say that you have had a magnetic resonance imaging (MRI) and injections. The Plan denied your request. The 
Plan says an office visit is not a covered chiropractic service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve an office visit (99203).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee brace. 
 
You asked the Plan to pre-approve a knee brace. You say that the brace will provide the support you need. The 
Plan denied your request. The Plan says duplicate items are not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a knee brace. Your current brace serves the same purpose as the requested knee 
brace. Based on this information, we decided that the Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a knee brace.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the expandable controller (E2377), harness (E2313) and electronic 
connector to 2 power options (E2311). 
 
You asked the Plan to pre-approve the power wheelchair (PWC) accessories. You say that the items are 
medically necessary. The Plan denied your request. The Plan says that the items are not medically necessary. 
 
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 power wheelchair (PWC) 
accessories. Our reviewer says that the items are medically necessary. Our physician reviewer found the 
complexity of your seating and positioning needs necessitates a more complex group 3 power wheelchair base. 
The expandable controller with harness and electronic connection are necessary to operate the group 3 power 
wheelchair base via the joystick. 
 
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 power wheelchair (PWC) accessories have been met. Therefore, we decided 
that the Plan has to pre-approve the expandable controller (E2377), harness (E2313) and electronic connector 
to 2 power options (E2311).  
 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the criteria for 
LTACH and needs the services to get back to prior level of functioning. The Plan denied your request. The 
Plan says the enrollee can safely receive this care in another setting, such as a skilled nursing facility or at 
home with home health services. 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital they are 
currently receiving 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on February 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says Per the plan documents, you are responsible for the 
difference in the allowed amounts. The allowed amount for periodontal maintenance is $150 and the allowed 
amount for the alternative level is $69, resulting in a $36 difference. 
 
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 If a method of 
treatment is more costly than is customarily provided, benefits will be paid on the least costly method of 
treatment, and you will be responsible for the remaining balance. 
 
You have been asked to pay $36 for dental services. 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 pay for the dental services 
provided on February 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service May 25, 
2022. 
 
You asked the Plan to pay for procedure code 99053. 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 99053 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99053 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99053 billed for date of service May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two additional intraoral periapical x-rays (D0230 x2) 
provided on August 25, 2022. 
 
You asked the Plan to pay for the additional intraoral periapical x-rays. You say that you were told that your 
insurance covered x-rays, which is why you thought this was covered. 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 August 25, 2022. 
Therefore, we decided that the Plan does not have to pay for the two additional intraoral periapical x-rays 
(D0230 x2) provided on August 25, 2022.