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

 
We decided that the Plan does not have to pay for electrical stimulator supplies, 2 leads, per month (A4595) 
provided on June 10, 2022. 
 
You asked the Plan to pay for electrical stimulator supplies. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says documentation submitted 
did not sufficiently support the billed supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for electrical stimulator supplies, 2 leads, per month (A4595) provided on June 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cervical, multiple post collar, occipital/mandibular supports 
(L0180) provided on August 4, 2022. 
 
You asked the Plan to pay for cervical, multiple post collar. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says documentation submitted 
did not sufficiently support the billed supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The record shows that the Plan made a call to 
the ordering provider, and they confirmed the provider did not order the denied item. Therefore, we decided 
that the Plan does not have to pay for cervical, multiple post collar, occipital/mandibular supports (L0180) 
provided on August 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on September 26, 2022. 
 
You asked the Plan to pay for a facility visit. You say that we depend on the facility staff to verify eligibility. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a facility visit provided 
on September 26, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for revascularization, endovascular, open or percutaneous, tibial, peroneal 
artery, unilateral, initial vessel; with transluminal angioplasty provided to the enrollee on July 27, 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 37228 is "Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial 
vessel; with transluminal angioplasty." 
 
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 record indicates that the enrollee 
had a ischemic chronic ulcer due to peripheral vascular disease for which he underwent endovascular 
intervention. The record indicates that separate angioplasty treatments were performed to separate lesions 
behind the knee popliteal and tibioperoneal arteries into the peroneal artery. The tibioperoneal trunk is 
considered part of any distal intervention in the peroneal artery. The elements of the coverage criteria are 
satisfied. 
 
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 
revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with 
transluminal angioplasty provided to the enrollee on July 27, 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 pre-approve a second opinion consultation to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve a consultation. You say that you are being treated for esophageal cancer and 
you are dissatisfied with the course of treatment within the network. You would like to have a second opinion 
with the requested facility. The Plan denied your request. The Plan says a second opinion with the requested 
facility is not medically necessary due to appropriate care is available within the Plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a second opinion consultation to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the retainer crown on tooth #'s 4, 6 (D6740) and the 
pontic on tooth #5 (D6245). 
 
You asked the Plan to pre-approve the dental services. You say that you have a problem with your dentist not 
covering a bridge replacement you received in 2018. 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 December 17, 2018. 
Therefore, we decided that the Plan does not have to pre-approve the retainer crown on tooth #'s 4, 6 (D6740) 
and the pontic on tooth #5 (D6245).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two additional home health skilled nursing visits 
(G0299). 
 
You asked the Plan to pre-approve home health services. You say that the additional skilled nursing visits are 
medically necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee does not have documented nursing needs. The enrollee has an available caregiver. Daily custodial 
supervision due to dementia is not skilled or intermittent. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve two additional home health skilled nursing visits (G0299).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 26, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you are requesting reconsideration on the 
denied claim and reprocess for payment. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on August 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an air assisted lateral turning device. 
 
You asked the Plan to pre-approve an air assisted lateral turning device. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested item 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 an air assisted lateral turning device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found you need assistance turning in bed. The documentation provided does 
not address your functional status or the efficacy of your current equipment. The medical necessity of the 
device is not evident in the records. Therefore, you do not meet criteria for the requested device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an air assisted lateral turning device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an air assisted lateral turning device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 16, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you need help because your dental services 
were denied. 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 January 13, 2022, April 
5, 2022, and April 12, 2022. Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation (D0140) provided on August 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 03, 2022. 
 
You asked the Plan to pay for the office visit. You say that staff was not informed that authorization was 
required. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on August 03, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0675 billed for dates of service March 3, 
2022, to March 23, 2022. 
 
You asked the Plan to pay for the billed services. You say that the device aids in the treatment of postoperative 
lymphedema. The Plan denied your request. The Plan says the device is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 We find that CPT code E0675 is only used in the treatment of peripheral arterial disease. Furthermore, a 
pneumatic compression device for the prevention of thromboembolism is excluded from coverage. Based on 
this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code E0675 billed for dates of service 
March 3, 2022, to March 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Hydrocodone-Acetaminophen tablet. 
 
You asked the Plan to pre-approve Hydrocodone-Acetaminophen. You say that the requested drug is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage of self-administered 
drugs have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with 
Hydrocodone-Acetaminophen tablet.  
 Benefits for Hydrocodone-Acetaminophen 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 cervical, multiple post collar, occipital/mandibular supports 
(L0180) provided on July 28, 2022. 
 
You asked the Plan to pay for cervical, multiple post collar. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says documentation submitted 
did not sufficiently support the billed supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for cervical, multiple post collar, occipital/mandibular supports (L0180) provided on July 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to further pay for procedure codes 99291 and 93010 billed for date of 
service May 22, 2022. 
 You asked the Plan to further pay for the billed services. You say that the codes are valid. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied.  
 
We looked at the file and Medicare rules. The file shows that the services at issue were reimbursed by the Plan 
on August 10, 2022. A comparison of the two claims shows these are duplicates. There is no evidence to 
support that the billed services were provided twice on the same date. CPT code 99291 will be used only once 
per date. Based on this information, we decided that the Medicare rules for the billed services have not been 
met. Therefore, we decided that the Plan does not have to further pay for procedure codes 99291 and 93010 
billed for date of service May 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0675 billed for dates of service January 21, 
2022, to February 15, 2022. 
 You asked the Plan to pay for the billed services. You say that the enrollee was treated for post-surgical 
lymphedema. The Plan denied your request. The Plan says the device is not covered to prevent deep vein 
thrombosis. 
 
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 E0675 is pneumatic compression device, high pressure, 
rapid inflation/deflation cycle, for arterial insufficiency (unilateral or bilateral system). We find that CPT code 
E0675 is not supported in the medical record. Code E0675 is only used in the treatment of peripheral arterial 
disease and denied as not medically necessary. Furthermore, a PCD for the prevention of venous 
thromboembolism is excluded from coverage. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code E0675 billed for dates of service January 21, 2022, to February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on October 6, 2022 
 
You asked the Plan to waive the copayment for office visit. You say that you are disputing the share cost. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $10 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
You have been asked to pay $10 copayment for office visit. This item/service 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 office visit provided on October 6, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve in-line cartridge containing digestive enzyme(s) for 
enteral feeding (B4105) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve enteral feeding supplies. You say that the requested provider is the only 
pharmacy in your area that covers your needed supplies. The Plan denied your request. The Plan says the 
requested OON provider is not contracted in your network. The service is available with an in-network 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
in-line cartridge containing digestive enzyme(s) for enteral feeding (B4105) to be provided by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWO) (E0483). 
 
You asked the Plan to pre-approve a HFCWO. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a HFCWO is covered when all criteria listed in 
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 a HFCWO. Our reviewer says that this 
item is not medically necessary. Our physician reviewer found there is no diagnosis of cystic fibrosis, 
bronchiectasis, or qualifying neuromuscular disease and there is no documentation of chronic productive cough 
or failure of other airway clearance treatments. 
 
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 HFCWO have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWO) (E0483).