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

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you would like the Plan to pay for your 
incontinence supplies that you require for bladder protection. You also say that you have the over-the-counter 
benefit for $45.00 per quarter, but it is not enough. The Plan denied your request. The Plan says the requested 
item is not covered by Medicare or the health plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for 
date of service July 31, 2021. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, and 88381. You say that the denial of 
payment is not correct. The Plan denied your request. The Plan says the testing must be billed with modifier 26. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an outpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, and 88381. 
This means there is both a professional and technical component for the CPT codes. In this case, an appropriate 
modifier to indicate the professional component has not been billed with CPT codes. Based on this information, 
we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for date of service July 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a push handle 8D, other accessories (K0108). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that the enrollee has shoulder weakness 
and pain that makes propelling a regular wheelchair damaging to his shoulder and needing extra care. The 
enrollee is not able to be independent without a lightweight wheelchair. The Plan denied your request. The Plan 
says the requested push handle does not primarily serve a medical purpose. The Push Handle 8D is for 
someone to push the enrollee. The Plan also says the enrollee is able to self-propel a wheelchair. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a push handle 8D, other accessories (K0108).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit (99202), electrical stimulation (G0283), and the x-ray 
exam of the lumbar spine (72100) provided on May 12, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that these services are not a covered benefit. 
 
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 has stated that the services at issue are not covered benefits 
by Medicare. However, the Plan contract offers supplemental coverage for 20 routine chiropractic visits every 
year for the relief of pain and neuromusculoskeletal disorders. The Plan has not provided rationale as to why 
these services rendered do not meet criteria for coverage under the chiropractic supplemental coverage policy. 
The Plan has not substantiated their denial; therefore, we must find in your favor. Therefore, we decided that 
the Plan has to pay for the office visit (99202), electrical stimulation (G0283), and the x-ray exam of the 
lumbar spine (72100) provided on May 12, 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: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance transportation services provided on May 12, 2022. 
 
You asked the Plan to pay for the transportation services. You say that the payment is incorrect. The Plan 
denied your request. The Plan says that the payment was made according to the Medicare allowable rate. 
 
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. 
 
We looked at the file and the rules. The explanation of benefits shows that the Plan paid $0.00 for the services 
at issue. The ambulance transportation services were not paid the correct amount based on the ambulance fee 
schedule. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for the ambulance 
transportation services provided on May 12, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Balversa tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that this medication is medically necessary. 
The Plan denied your request. The Plan says this drug is not covered by 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 Balversa tablets.  
 
Benefits for self-administered drug 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: 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 it would be in the best interest for the 
enrollee. The Plan denied your request. The Plan says the enrollee can stay in the hospital until they are safe for 
transfer or discharge. 
 
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 record indicates that the enrollee remains critically ill and still requires acute care 
services. The enrollee continues to receive acute care services, and these have not been denied. The medical 
record does not indicate that the enrollee requires services they are not currently receiving but that would be 
available at the LTACH facility. 
 
 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing is medically necessary as ordered by 
the referring physician. The Plan denied your request. The Plan says these services are not covered. 
 
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 lab services have been met. In this 
case medical records were not provided to review medical necessity of the claims or whether criteria for coverage are met. Therefore, we decided that the Plan does not have to pay for the lab services provided on 
February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet join injections (64493, 94494). 
 
You asked the Plan to pre-approve facet join injections. You say that this service is medically necessary. The 
Plan denied your request. The Plan says this service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered when the criteria 
listed in the Medicare Rules section is 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 facet join injections. Our reviewer says 
that this service is not medically necessary. Our physician reviewer found the patient has not had two (2) 
medically reasonable and necessary diagnostic facet joint procedures with each one providing a consistent 
minimum of 80% relief of primary (index) pain (with the duration of relief being consistent with the agent 
used). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet join injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet join injections (64493, 94494).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tilt-in-space push wheelchair. 
 
You asked the Plan to pre-approve wheelchair. You say that you are a requesting a denial due to the place of 
service. The Plan denied your request. The Plan says Medicare does not separately cover durable medical 
equipment (DME) for use in a skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that the 
Plan does not have to pre-approve a tilt-in-space push wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interim dental crowns (D2799 x 2). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested items are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve interim 
dental crowns (D2799 x 2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related supplies 
provided on May 23, 2022. 
 
You asked the Plan to pay for the billed services. You say that the equipment was issued for use during 
surgery. The Plan denied your request. The Plan says the devices are not separately payable. 
 The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The file shows that the items at issue were provided in an ambulatory surgical center. The items at issue were 
used outside of the home. Neither Medicare nor the Plan covers equipment for use outside the home. Therefore, 
we decided that the Plan does not have to pay for the pneumatic compression device and related supplies 
provided on May 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a proton beam radiation therapy (PBRT) (77523). 
 
You asked the Plan to pre-approve a proton beam radiation therapy (PBRT). You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is 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 a proton beam radiation therapy 
(PBRT). Our reviewer says that the requested service is not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is insufficient prospective, long-term clinical data available to 
determine whether or not proton beam radiation therapy for prostate cancer is superior, inferior, or equivalent 
to external beam radiation therapy, Intensity-modulated radiation therapy (IMRT), or brachytherapy with 
regards to safety and efficacy. Recent data shows no significant differences in late (years one, two, and three) 
patient-reported toxicity outcomes between proton beam therapy and IMRT. 
 
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 proton beam radiation therapy (PBRT) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a proton beam radiation therapy (PBRT) (77523).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), expandable 
controller (E2377), electronic connection between wheelchair controller and two or more power seating system 
motors (E2311), and harness for upgrade to expandable controller (E2313). 
 
You asked the Plan to pre-approve a power seat elevation system, expandable controller, electronic connection, 
and harness. You say that the services are necessary. The Plan denied your request. The Plan says based on the 
documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchairs and accessories 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 a power seat elevation system, 
expandable controller, electronic connection, and harness. Our reviewer says that the services are not medically 
necessary. Our physician reviewer found a seat elevator is not medically necessary as it does not serve a 
primary medical purpose and is statutorily non-covered. The enrollee's right upper extremity range of motion 
and function supports that the enrollee can control any power options through their own switches. The 
requested items exceed the enrollee's medical needs and does not meet Medicare medical necessity criteria. 
 
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 seat elevation system, expandable controller, electronic connection, and 
harness have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat 
elevation system (E2300), expandable controller (E2377), electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), and harness for upgrade to expandable controller 
(E2313).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion supplies not used with external infusion pump, per 
cassette or bag (A4223) provided on July 13, 2022, to July 19, 2022. 
 
You asked the Plan to pay for infusion supplies. You say that you provided IV infusion therapy for the enrollee 
at home and the home IV infusion supplies was omitted from the reimbursement. You are requesting 
reprocessing and payment on this claim. The Plan denied your request. The Plan says this is an administrative 
determination for non-coverage and is not based on clinical criteria for medical necessity. Disposable drug 
delivery systems, including elastomeric infusion pumps are non-covered devices because they do not meet the 
Medicare definition of durable medical equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Medicare rules say that disposable drug delivery systems, including elastomeric infusion pumps are non-
covered devices because they do not meet the Medicare definition of durable medical equipment. Drugs and 
supplies used with disposable drug delivery systems are also non-covered items. Based on this information, we 
decided that Medicare rules for coverage of infusion supplies have not been met. Therefore, we decided that the 
Plan does not have to pay for infusion supplies not used with external infusion pump, per cassette or bag 
(A4223) provided on July 13, 2022, to July 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shoulder nerve block (pain injection) (64640). 
 
You asked the Plan to pre-approve a nerve block injection. You say that the enrollee is in severe constant pain 
and cannot do things by themselves. The Plan denied your request. The Plan says this type of injection is 
considered experimental and investigational as the safety and effectiveness has not been established. 
 
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 
overage of a nerve block injection have not been met. Therefore, we decided that the Plan does not have to pre-
approve a shoulder nerve block (pain injection) (64640).
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 October 10, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 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 October 
10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on September 5, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
simply called 911 and you had no choice of in-network or not. The Plan denied your request. The Plan says 
these services are not a covered benefit. 
 
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 September 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 response and treatment with no 
transport provided on September 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that without these services the enrollee is at great risk for 
readmission. The Plan denied your request. The Plan says the enrollee can safely receive the services needed in 
another setting such as a skilled nursing facility or home with home health services. 
 
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 treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 inpatient rehabilitation facility (IRF) admission and services.