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

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliances (E0673) provided August 30, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliances. You say that the equipment was 
prescribed by the doctor and was issued to the enrollee for use during their surgery. The Plan denied your 
request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following 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 segmental pneumatic appliances (E0673) provided 
August 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Febuxostat 40mg tablets. 
 
You asked the Plan to pre-approve Febuxostat. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Febuxostat 40mg tablets.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection testing provided on March 30, 
2022. 
 
You asked the Plan to pay for the infectious agent detection testing. You say that you are unable to obtain 
medical records. The Plan denied your request. The Plan says there was insufficient information provided to 
review this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the infectious agent detection testing have been met. The Plan provided documentation showing that multiple requests for medical records were sent. 
Medical records were not provided. Thus, there is insufficient documentation provided to verify the medical 
necessity of the testing.  Therefore, we decided that the Plan does not have to pay for the infectious agent 
detection testing provided on March 30, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the take home supply of methadone (G2068) provided on October 
31, 2022. 
 
You asked the Plan to pre-approve the outpatient service. You say that the facility in this case is certified by the 
Substance Abuse and Mental Health Services Administration (SAMHSA). The Plan denied your request. The 
Plan says that this claim does not meet the opioid treatment program criteria for payment. 
 
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 Plan's rationale is not supported. The rules that the Plan cited do 
not appear to prohibit payment to the program if the prescribing physician is listed on the claim. Therefore, we 
decided that the Plan has to pre-approve the take home supply of methadone (G2068) provided on October 31, 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the group psychotherapy services (90853) provided June 1, 
2022, to June 7, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that please be advised that the enrollee 
attends the facility for substance abuse rehabilitation, and this is not a benefit that Medicare covers. Please 
reprocess the above-mentioned claims. The Plan denied your request. The Plan says the services was rendered 
by a provider that is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. The case file included a letter that the providers application to enroll in Medicare was denied. 
Therefore, we decided that the Plan does not have to pay for the group psychotherapy services (90853) 
provided June 1, 2022, to June 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coverage for supplemental benefit for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve coverage for SSBCI. You say that you are appealing the denial for SSBCI 
benefits. The Plan denied your request. The Plan says the provider returned an attestation form stating that the 
enrollee does not meet the criteria for the expanded benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of coverage for SSBCI have not been met. Specifically, we have confirmed that you do not have one 
of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have 
to pre-approve coverage for supplemental benefit for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that you are requesting a formal 
mixed decision to independently review these items and issue formal determination in order to pursue other 
funding resources for these items. The Plan denied your request. The Plan says this item is not primarily 
medical in nature and is not covered. 
 
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 power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system (E2300).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has pre-approve continued SNF care. 
 
You asked the Plan pre-approve continued SNF care.. You say that you have COVID-19 and need SNF care. 
The Plan denied your request. The Plan says that continued SNF care is not medically necessary. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily 
skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has pre-
approve SNF care.  
 
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 power seat elevation system (E2300). 
 
You asked the Plan to pre-approve A power seat elevation system. You say that you need this device to help 
you perform everyday activities and to help lessen the risk of falling. The Plan denied your request. The Plan 
says this item is not primarily medical in nature and is not covered. 
 
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 power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system (E2300).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the medication assisted treatment, methadone, (G2067) provided on 
October 10, 2022. 
 
You asked the Plan to pay for the outpatient service. You say that the provider is certified by Substance Abuse 
and Mental Health Service Administration (SAMHSA). You also say that this should be reprocessed and paid. 
The Plan denied your request. The Plan says that this claim does not meet the opioid treatment program criteria 
for payment. 
 
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 Plan's rationale is not supported. The rules that the Plan cited do 
not appear to prohibit payment to the program if the prescribing physician is listed on the claim. Therefore, we 
decided that the Plan has to pay for the medication assisted treatment, methadone, (G2067) provided on 
October 10, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ESRD-related laboratory services provided on October 
12, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the services at issue have 
been billed correctly. 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 ESRD-related laboratory services provided on October 12, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit provided on June 16, 2022. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says that this charge is incidental to another 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. Review of the file shows that the Plan states this charge is incidental to another 
service. The documentation did not include explanation on what services this charge is incidental to. No other 
denial rationale was provided. The Plan did not substantiate their denial. Therefore, we decided that the Plan 
has to pay for the office visit provided on June 16, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexcom G6 Receiver. 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary. The Plan denied 
your request. The Plan says the Medicare rules 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 enrollee has not met any of the following criteria: -requires 
multiple (three or more) daily doses of insulin; -requires treatment with a continuous subcutaneous insulin infusion pump; -requires frequent daily adjustments of insulin based on blood glucose testing results. Based on 
this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Dexcom G6 Receiver.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the expandable controller (E2377), harness (E2313), and 
electronic connection (E2311). 
 
You asked the Plan to pre-approve the expandable controller, harness, and electronic connection. 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 if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 expandable controller, harness, and 
electronic connection. Our reviewer says that the requested items are considered medically reasonable and 
necessary in this case. Our physician reviewer found the patient is non-ambulatory and requires a power 
wheelchair for mobility and performing her basic daily activities. She cannot perform pressure relief 
independently due to weakness and spasticity and requires a power wheelchair with power tilt and recline for 
adequate pressure relief and positioning. She also requires power elevating leg rests for positioning, lower 
extremity lymphedema, and lower extremity spasticity. The complexity of her 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 and the power tilt and recline 
and power elevating leg rests via a joystick, which is required to coordinate the operation of the wheelchair 
power base and power tilt and recline and power elevating leg rests. 
 
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 expandable controller, harness, and electronic connection have been met. 
Therefore, we decided that the Plan has to pre-approve the expandable controller (E2377), harness (E2313), 
and electronic connection (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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the microprocessor knee and advanced foot coded as 
L5624, L5828, L5920, LK5848, L5848, L5856, L5981 and L5968. 
 
You asked the Plan to pre-approve the microprocessor knee and advanced foot. You say that the leg that the 
enrollee wants will help with walking long distances. The enrollee wants to be able to get around without a 
cane. The Plan denied your request. The Plan says the current knee and foot is less than 2 years old and under warranty. The physician officer visit notes do not corroborate the vendor's notes. The prosthetist is also the 
vendor and therefore has financial interest in the outcome of the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare does not cover replacement of items under manufacturer's 
warranty. Records from suppliers or healthcare professionals with a financial interest in the claim outcome are 
not considered sufficient by themselves for determining that an item is reasonable and necessary. Based on this 
information, we decided that Medicare rules for coverage of the microprocessor knee and advanced foot have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the microprocessor knee and 
advanced foot coded as L5624, L5828, L5920, LK5848, L5848, L5856, L5981 and L5968.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 13, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service should be covered. 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 July 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xhance. 
 
You asked the Plan to pre-approve Xhance. You say that the enrollee has been using this drug since October 
2021. You also say that the enrollee has tried and failed at least four other nasal sprays. The Plan denied your 
request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not 
covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xhance.  
 Benefits for Xhance may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies provided on September 14, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that the proof of 
delivery did not include an order number or details to corroborate the delivery ticket submitted. 
 
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. The Plan argues that the proof of delivery did not include an order number or 
details to corroborate the delivery ticket submitted. However, the records contain a an itemized packing slip 
dated September 14, 2022, with the same tracking number as the delivery ticket dated September 20, 2022. As 
the documentation shows that the items in question were delivered, the Plan's denial cannot be substantiated. 
Therefore, we decided that the Plan has to pay for the electrical stimulator supplies provided on September 14, 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polish and cleaning (V2624), orbital prosthesis (L8042), 
and unlisted prosthetic service (L8499) provided on August 17, 2022. 
 
You asked the Plan to pay for the prosthetic services. You say that you have treated the enrollee for this 
condition for several years. You say that you have an in-network authorization The Plan denied your request. 
The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the polish and cleaning (V2624), orbital 
prosthesis (L8042), and unlisted prosthetic service (L8499) provided on August 17, 2022.