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

 
We decided that the Plan does not have to pre-approve a mobile cardiac outpatient telemetry (MCOT) monitor 
 
You asked the Plan to pre-approve an MCOT monitor. You say that the records provided support the need for 
the services in dispute. The Plan denied your request. The Plan says the request 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 MCOT monitor. Our reviewer says 
that the MCOT monitor is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has no cardiac symptoms, and the issue now appears resolved according to the 
documents submitted. As such, guidelines would not support a need for MCOT monitoring in this setting. 
There was insufficient documentation to support the medical necessity for an MCOT monitor in this patients 
clinical management at this time. 
 
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 MCOT monitor have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a mobile cardiac outpatient telemetry (MCOT) monitor
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76706 billed for date of service October 7, 
2022. 
 
You asked the Plan to pay for procedure code 76706. The Plan denied your request. The Plan says payment for 
code 76706 is bundled into payment for code 93975.  
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, we have confirmed that code 76706 
is a column II code to column I code 93975. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76706 billed for date of service October 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Medicare Part B prescription drugs 
provided on September 22, 2022. 
 
You asked the Plan to waive the copayment for Medicare Part B prescription drugs. You say that you disagree 
with the coinsurance. 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 a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
 
 
 
 
 
 
 You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs. The total allowed 
amount for the Medicare drugs is $3,208.40. You are being asked to pay $641.68 ($3,208.40 x 20% = 
$641.68). This item/service falls within the Medicare Part B prescription drugs 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 Medicare Part B prescription drugs provided on September 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 13, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for waterproof tape (A4452) and specialty absorptive dressing, 
wound cover, sterile, pad (A6252) provided on June 7, 2022. 
 
You asked the Plan to pay for waterproof tape and absorptive dressing pads. You say that you disagree with the 
denial and have submitted medical records for review. The Plan denied your request. The Plan says the 
documentation submitted did not include a valid physician order for the billed supplies, therefore, the billed 
service cannot be verified. 
 
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 for the billed 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 waterproof tape (A4452) and specialty absorptive dressing, 
wound cover, sterile, pad (A6252) provided on June 7, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are medically necessary to help you 
become stronger and have more time to heal. The Plan denied your request. The Plan says that the services can 
be met in another setting such as, home with home health care, in residential care or at home with close follow-
up with your doctor. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. you do 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do require daily skilled therapy on an inpatient basis in a SNF setting. Ongoing 
daily skilled services are required to establish a maintenance program or to prevent deterioration of your 
condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 this service is medically necessary. The 
Plan denied your request. The Plan says this service is not medically necessary. 
 
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 there are no services at the LTACH that the patient requires that are not already 
available and covered at the current 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. Specifically, medically necessary 
services are being obtained at the enrollee's current level of care.  This means admission into an LTACH is not medically necessary. Therefore, we decided that the Plan does not 
have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional reimbursement for the acupuncture treatments 
(97810) provided from October 3, 2021, through November 10, 2021. 
 
You asked the Plan to issue additional reimbursement 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 the correct 
reimbursement has been issued to you previously in the amount of $285. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and the Plans rules. Based on this information, we decided that the rules for additional 
coverage of the acupuncture services provided have not been met. Specifically, the supplemental acupuncture 
benefit allows for reimbursement in the amount of $300 each calendar year. The Plan previously issued 
payment to you in the amount of $285 for the acupuncture services provided. Although, you have stated that 
you should be reimbursed for additional money allocated for these services, the submitted receipts from the 
provider only total up to $285. Therefore, we decided that the Plan does not have to issue additional 
reimbursement for the acupuncture treatments (97810) provided from October 3, 2021, through November 10, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for positive airway pressure (PAP) device tubing (A7037) 
provided on August 2, 2022. 
 
You asked the Plan to pay for the tubing. The Plan denied your request. The Plan says this exceeds the 
maximum allowed amount. 
 
The Plan must follow Medicare rules. Medicare rules say that the usual maximum amount of code A7037 
expected to be reasonable and necessary is one per three months. Quantities of supplies greater than those 
described in the policy as the usual maximum amounts will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The records show that tubing was provided and paid by the Plan 
within three months prior to the tubing in question being provided. This means that the requested tubing 
exceeds the limit set by LCD L33718. Based on this information, we decided that Medicare rules for coverage 
of the tubing have not been met. Therefore, we decided that the Plan does not have to pay for positive airway 
pressure (PAP) device tubing (A7037) provided on August 2, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient office visits (99215) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the office visits. You say that the enrollee has been in this doctor's care 
since August 15, 2019 and has since received radiation treatment. The enrollee now has brain metastasis and 
needs more radiation. The enrollee needs continuation of care instead of starting all over with a new provider. 
The Plan denied your request. The Plan says enrollees must receive their medical services from an in-network 
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 
providers require prior authorization before services being rendered. 
 
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 
the outpatient office visits (99215) 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 pay for the power operated vehicle (three- or four-wheel 
nonhighway) specify brand name and model number (E1230) and General use wheelchair seat cushion, width 
less than 22 inches, any depth (E2601) purchased August 5, 2022. 
 
You asked the Plan to pay for the power scooter. You say that you have MS and cannot walk or stand. You 
need a mobility scooter instead of a wheelchair. You were not informed that a home inspection was needed. 
 The Plan denied your request. The Plan says the medical necessity criteria has not been met for Medicare 
coverage of the requested durable medical equipment. 
 
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 pay for the power scooter. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found according to Medicare a power mobility device is medically necessary if a beneficiary has a 
mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related 
activities of daily living.  The mobility limitation cannot be sufficiently and safely resolved by the use of a 
fitted cane or walker, or the beneficiary does not have sufficient upper extremity function to self-propel an 
optimally configured manual wheelchair.  Additionally, if any POV or PWC is only for use outside the home, it 
is denied as noncovered.  The member must also have the mental and physical capabilities to safely operate the 
power wheelchair and the home provides adequate access between rooms, maneuvering space, and surfaces for 
the operation of the PWC. In this case, the documentation does not support that a home evaluation has been 
completed to assess if the scooter can be safely used in the home. The criteria for a scooter/PMD is not met. 
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pay for the power operated vehicle (three- or four-wheel nonhighway) specify brand name and 
model number (E1230) and General use wheelchair seat cushion, width less than 22 inches, any depth (E2601) 
purchased August 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eustachian tube balloon dilation. 
 
You asked the Plan to pre-approve Eustachian tube balloon dilation. You say that your doctor is requesting that 
you have Eustachian tube balloon dilation because you have had continual fluid retention in your ears since 
January, and you are not a candidate for tubes since you have already had them with no relief. You say that 
currently you have a hole in your right eardrum due to the fluid and Eustachian tube balloon dilation is the final 
step to get some relief and stop the hearing loss from getting any worse. The Plan denied your request. The 
Plan says Eustachian tube balloon dilation is experimental/investigational treatment. 
 
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 Eustachian tube balloon dilation. Our 
reviewer says that the requested Eustachian tube balloon dilation is not considered medically reasonable and 
necessary. Our physician reviewer found that the record indicates that you have chronic eustachian tube 
dysfunction. The record provided is insufficient to establish the medical necessity of the requested procedure. 
There is insufficient literature to support the use of the requested procedure for your clinical condition as 
described in the records provided. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eustachian tube balloon dilation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Eustachian tube balloon dilation.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 14, 2022, 
to March 15, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 14, 2022, to 
March 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 5, 
2022. 
 
You asked the Plan to pay for procedure code 76641. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service October 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minute Man procedure (27279). 
 
You asked the Plan to pre-approve the Minute Man procedure. 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 the Minute Man procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there are multiple alternate pain generators plausibly significantly contributing to 
the clinical condition that have not been fully documented as having been excluded and/or ruled out. There is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 Minute Man procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Minute Man procedure (27279).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity (CPT code J3111). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says they do have a record from the enrollee's prescriber that shows they have tried the 
preferred drug Forteo and it has not worked, or that they have medical reasons that prevent the enrollee from 
using it. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our physician reviewer 
found the case file does not contain documentation of trial and failure of Forteo. The documentation does not 
support that Forteo would likely be less effective, and/or would likely have adverse effects for the enrollee in 
this case. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Evenity (CPT code J3111).