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

 
We decided that the Plan does not have to pre-approve a Group 3 PWC with multiple power options (K0861) 
and attachments for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the member does not have medical need for multiple power 
options included with this power wheelchair. 
 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The patient has a 
Group 3 qualifying diagnosis of a neurological condition. The documentation indicates the patient has a 
mobility deficit that impairs MRADLs in the home and cannot be overcome with a manual wheelchair, walker, 
or cane due to poor endurance, weakness and safety issues. While the patient may be able to safely use the 
requested wheelchair the documentation does not reveal that the requested chair with multiple power options is 
medically necessary. The documentation does not reveal that the patient uses a ventilator attached to a 
wheelchair, is at high risk for development of a pressure ulcer, and there is no evidence of intermittent 
catheterization. The physician documentation does not indicate objective evidence of spasticity on a bilateral 
lower extremity physical exam that needs a power seating system for management. The request for a Group 3 
power wheelchair with multiple accessories exceed the patient's medical need. Our physician reviewer found 
that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 3 PWC with multiple power options (K0861) and attachments for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the enrollee needs 
additional transportation. The Plan denied your request. The Plan says that the requested amount exceeds the 
Plan limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of seventy-two (72) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan does not have to provide routine transportation above the benefit maximum of seventy-two (72) 
routine transportation trips. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation trips for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair repairs. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the wheelchair is under warranty. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment can be made for reasonable and 
necessary maintenance and service of beneficiary-owned DME that is not under a manufacturers or suppliers 
warranty. 
 
We looked at the file and Medicare rules. The file shows that the requested repairs are for a wheelchair that is 
currently covered under a manufacturer's warranty. Based on this information, we decided that Medicare rules 
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-
approve power wheelchair repairs.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cystourethroscopy provided on December 
30, 2021. 
 
You asked the Plan to waive the copayment for a cystourethroscopy. You say that the copayment should be 
included in the procedure cost. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 a $40 
copayment for services obtained from a specialist.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$40 copayment for a cystourethroscopy. A cystourethroscopy falls within the Physician/Practitioner Services, Including Doctors Office Visits 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 a 
cystourethroscopy provided on December 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on November 30, 
2021. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you have already paid the 
copayment upon your visit to the doctor. The Plan denied your request. The Plan says you have been charged 
the correct copayment amount. 
 
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 a $5 
copayment for each Medicare-covered specialist visit.  
 
You have been asked to pay a $5 copayment for a specialist visit. The specialist visit falls within the 
Physician/Practitioner services, including doctors office visits 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 a specialist visit provided on November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection, of diagnostic or therapeutic substances (eg, 
anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle 
or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic (62320) provided December 
6, 2021. 
 
You asked the Plan to pay for the injection services. You say that this treatment is part of a comprehensive pain 
management program that has been implemented since all conservative measures also including more 
aggressive therapies such as surgical intervention has failed. The Plan denied your request. The Plan says the 
provider has not submitted the required clinical records to support medical necessity of the services.  
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 injection, of diagnostic or therapeutic 
substances (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, 
including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic (62320) 
provided December 6, 2021. have been met. The records provided are not dated and unsigned. Therefore, we 
decided that the Plan does not have to pay for injection, of diagnostic or therapeutic substances (eg, anesthetic, 
antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter 
placement, interlaminar epidural or subarachnoid, cervical or thoracic (62320) provided December 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bidet purchased September 1, 2021. 
 
You asked the Plan to pay for a bidet. You say that due to your specific circumstances, this is a health and 
safety issue and should be covered. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that bidets are not covered because they 
are not primarily medical in nature.  
 
While a bidet may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for a bidet purchased September 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 24, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on November 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a raised toilet seat you purchased on December 24, 2021. 
 
You asked the Plan to pay for a raised toilet seat. You say that you moved to a new rental home and the toilet 
was too low for you.  You said that this device has been helpful for you. The Plan denied your request. The 
Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a raised toilet seat you purchased on 
December 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 26, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 March 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ondansetron 8mg tablets. 
 
You asked the Plan to pre-approve the ondansetron tablets. You say that this is necessary to treat nausea. The 
Plan denied your request. The Plan says since this is not being used during chemotherapy, it is covered by 
Medicare Part D. 
 
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 ondansetron 8mg tablets.  
 Benefits for the ondansetron tablets 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: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the MyoPro is supported as an appropriate 
intervention and is reasonably and medically necessary as recognized by medical communities and key opinion 
leaders in rehabilitation. The Plan denied your request. The Plan says this item is considered experimental and 
investigational. There is insufficient evidence of its effectiveness in those with this enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G orthotic device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with a single power option 
for power tilt (K0856, E2361, E1028, E1002, E0955, E1012, E2311, E2605). 
 
You asked the Plan to pre-approve the group 3 power wheelchair with a single power option for power tilt. You 
say that this type of wheelchair is medically necessary. The Plan denied your request. The Plan says the group 
3 power wheelchair with power options exceeds the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that a power tilt feature is covered only 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 a 
single power option for power tilt. Our reviewer says that the requested power wheelchair is not medically 
necessary. Our physician reviewer found the member has a neurologic disorder with functional deficits. While 
she meets criteria for use of a power mobility device, the documentation does not indicate that the member has 
any pressure injuries or requires intermittent catheterization of the bladder. The requested power tilt 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 group 3 power wheelchair with a single power option for power tilt have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with a 
single power option for power tilt (K0856, E2361, E1028, E1002, E0955, E1012, E2311, E2605).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on August 25, 2021. 
 
You asked the Plan to pay for the medical services. You did not provide a specific argument in your appeal 
request. The Plan denied your request. The Plan says the patient was enrolled in hospice on the date of service 
in question. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on August 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need this because you will 
be traveling. The Plan denied your request. The Plan says the requirements for coverage have not been met. 
 
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 item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on September 30, 
2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that you did not meet this person. You 
say that you did not want to see anyone anymore as you have not had a good experience. The Plan denied your 
request. The Plan says you have been charged the correct copayment amount. 
 
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 a $10 
copayment for per visit to all non-preferred primary care providers for Medicare-covered services.  
 
 
 
 
 You have been asked to pay a $10 copayment for the office visit. The office visit falls within the 
Physician/Practitioner services, including doctor's office visits 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 an office visit provided on September 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurophysiology services provided to the enrollee on 
February 22, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 95886: 
 
Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve 
conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three 
or more nerves or four or more spinal levels (List separately in addition to code for primary procedure) 
 
CPT 95907:  
Nerve conduction studies; 1-2 studies 
 
CPT 95937: 
 
Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 
 
CPT 95957: 
 
Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found there was no documentation that CPT 
95907 was provided in this case. There was no evidence that a nerve conduction study (NCS) had been 
performed. Rather, testing of pedicle screws is considered to be triggered electromyography (EMG) (and is 
coded as an EMG). This code is not supported. Given the absence of a NCS during this episode of care, billing 
of CPT 95886 would not have been appropriate. Rather, there would have been a more appropriate CPT code 
to have been used to reflect the EMG services provided. There was no evidence that single fiber EMG testing 
was provided for evaluation of a disease of the neuromuscular junction. In such a setting the use of CPT code 
95937 was not appropriate. This code is otherwise not recommended for use in reflecting train of four testing 
(which is otherwise inherent to other billed services). Finally, there was no clinical documentation that formal 
digital analysis was done during the procedure. The use of automated computer algorithms for 
electroencephalogram (EEG) evaluation is not consistent with CPT code 95957. In as much this service would 
also have not been considered to have been coded properly. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for neurophysiology services provided to the enrollee on February 22, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 13, 2021, to 
August 31, 2021. 
 
You asked the Plan to pay for the home health services. You say that these services were not related to the 
patient's terminal diagnosis, so these claims should be paid. The Plan denied your request. The Plan says they 
are not responsible for these services due to the member's hospice status. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on August 13, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for home health services 
provided from August 13, 2021, to August 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a lightweight wheelchair is 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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the records show that you have a mobility 
limitation that cannot be sufficiently resolved by the use of an appropriately-fitted cane or walker. You have a 
manual wheelchair that can be repaired for continued use. The documentation does not support that the 
requested lightweight wheelchair will fit into your home more readily than the current 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lightweight wheelchair.