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

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options and features. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no medical need for these items. 
 
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 the wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that the 
provided records do not document necessity of the single power option and power tilt. The provided records do 
not support that the patient is high risk for skin breakdown (she walks short distances with a walker or by 
holding onto walls or furniture and is reported to be independent/minimum assist for transfers); records do not 
report a history of pressure ulcer(s) or skin flap surgery. Records do not document the patient performs bladder 
self-catheterization and is unable to transfer independently or that she has increased muscle tone or spasticity. 
Therefore, she does not meet Medicare criteria for the single power option (power tilt). As the power 
wheelchair base is not covered, the requested accessories are not covered.  
 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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair with multiple power options and features.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the noncovered item or service (A9270) provided October 
27, 2022, to October 28, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you are requesting reconsideration for 
$350.62 for medication that was given to you while you were in the hospital after surgery. The Plan denied 
your request. The Plan says under Medicare guidelines, code A9270 is not paid under the Outpatient 
Prospective Payment System (OPPS) or any other Medicare payment system. 
 
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 pay for the noncovered item or service 
(A9270) provided October 27, 2022, to October 28, 2022.   
Benefits for the self-administered drugs 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 pay for the wheelchair purchased on June 27, 2022. 
 
You asked the Plan to pay for the wheelchair. You say that you needed this item. The Plan denied your request. 
The Plan says this item was purchased through a provider that is not enrolled in 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. Therefore, we decided that the Plan does not have to pay for the wheelchair purchased on June 27, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on November 16, 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 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 November 4, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on November 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom back cushion, custom seat cushion, and repairs 
for your wheelchair. 
 
You asked the Plan to pre-approve wheelchair accessories and repairs. You say that the requested items are 
medically necessary for the enrollee. The Plan denied your request. The Plan says durable medical equipment 
is not covered by Medicare or the Plan for use outside of the home. 
 
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 accessories and repairs are being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a custom back cushion, custom seat cushion, 
and repairs for your wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life2000 non-invasive home ventilator. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 item. Our reviewer says that the 
requested item is not medically reasonable or necessary. Our physician reviewer found that the provided 
records document that the home ventilator is being requested for use with very low set tidal volumes (150 to 
200 mL) which could be provided by a bilateral positive airway pressure (BiPAP) device with average volume-
assured pressure support (AVAPS) and a back-up rate. 
 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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Life2000 non-invasive home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on October 19, 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 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 September 11, 2020. 
Therefore, we decided that the Plan does not have to pay for the dental services on October 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says criteria for admission to the IRF have not been met. 
 
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an IRF stay. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical therapy and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (code E0676) and sleeve for 
intermittent limb compression device (code A4600) provided on May 5, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and sleeve for intermittent limb compression 
device. You say that the pneumatic compression device and sleeve for intermittent limb compression device 
was medically necessary. The Plan denied your request. The Plan says pneumatic compression devices for the 
prevention of illnesses/disease including DVT 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 pneumatic compression device and 
sleeve for intermittent limb compression device have been met. Specifically, you have not provided sufficient 
and complete medical records. Therefore, we decided that the Plan does not have to pay for a pneumatic 
compression device (code E0676) and sleeve for intermittent limb compression device (code A4600) provided 
on May 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an elbow orthosis provided to the enrollee on September 29, 
2022. 
 
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 documentation submitted did not sufficiently support the billed supply code. 
 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the records do not document any history of elbow pain or any physical examination of the elbow 
showing tenderness or other abnormality or a treatment plan that involves the use of an elbow orthosis. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for an elbow orthosis provided to the enrollee on September 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed (87625) provided 
June 21, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the claim denied for non-covered service, 
and you have attached the medical records. The Plan denied your request. The Plan says service is not covered 
by Medicare per Medicare LCD. 
 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. Per LCA A58710, CPT code 87625 is listed under a Group 8 code 
that is conditionally a non-covered CPT code. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 
18 only, includes type 45, if performed (87625) provided June 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on November 18, 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 the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services on November 18, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (procedure code 63056 and 63057) rendered on 
October 7, 2022. 
 
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 that the denied code was not supported by the medical records submitted. 
 
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 63056: 
 
Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated 
intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far 
lateral herniated intervertebral disc) 
 
CPT 63057: 
 
Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated 
intervertebral disc), single segment; each additional segment, thoracic or lumbar (List separately in addition to 
code for primary procedure) 
 
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 supported by the medical records. Our reviewer found that the procedure details cite the working 
channel was manually held in position while a series of disc cleaning tools was passed through the channel to 
remove the affected discs under clear and direct biplanar fluoroscopic visualization, decompression the nerve 
roots, and decorticate the vertebral endplates at those segments. This was performed at L1/2, L2/3, and 
L3/4. Therefore, the records do support that CPT 63056 and CPT 63057 were rendered in this case. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
surgical services (procedure code 63056 and 63057) rendered on October 7, 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 Guidance UTI provided on September 27, 2022. 
 
You asked the Plan to pay for the Guidance UTI. You say that this testing should be covered. The Plan denied 
your request. The Plan says this testing is not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that that molecular diagnostic laboratory tests are 
subject to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the Guidance UTI have not been met. Therefore, 
we decided that the Plan does not have to pay for the Guidance UTI provided on September 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the noncovered item or service (A9270) and 
unlisted special services, and other medical services and procedures (99199) serviced provided September 26, 
2022, by an out-of-network provider. 
 
You asked the Plan to reimburse you for the screening services. You say that you are appealing the denial of 
reimbursement. The Plan denied your request. The Plan says the services are not covered and was rendered by 
a provider who does not participate in the Medicare program. 
 
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 reimburse you for the noncovered item or 
service (A9270) and unlisted special services, and other medical services and procedures (99199) serviced 
provided September 26, 2022, by an out-of-network provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for closed treatment of distal fibular fracture (lateral malleolus); without 
manipulation provided to the enrollee on June 26, 2022. 
 
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 that 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 
code 27786 is "Closed treatment of distal fibular fracture (lateral malleolus); without manipulation." 
 
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 supported by the medical records. Our reviewer found that the enrollee was being treated for 
fracture of upper and lower end of the right fibula. The enrollee presented with moderate right ankle pain. The 
right lateral ankle exam reveals moderate tenderness, swelling, and deformity consistent with a closed fracture. 
A posterior fiberglass splint was applied to the right ankle. The application of the fiberglass splint is closed 
treatment for a fracture. Therefore, the records do support that the CPT 27786: closed treatment of distal fibular 
fracture (lateral malleolus); without manipulation was rendered in this case. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
closed treatment of distal fibular fracture (lateral malleolus); without manipulation provided to the enrollee on 
June 26, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on November 3, 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 the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services on November 3, 2022.