Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the partial denture (D5212). 
 
You asked the Plan to pre-approve the partial denture. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the plan benefit for this service has 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. The Plan covers partial 
dentures once every five plan years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Specifically, the plan benefit for this service has been exhausted. 
Therefore, we decided that the Plan does not have to pre-approve the partial denture (D5212).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76775 billed for date of service August 2, 
2022. 
 
You asked the Plan to pay for procedure code 76775. You say that this service is supported as billed. The Plan 
denied your request. The Plan says payment for code 76775 is bundled into payment for code 76770. 
 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 76775 
is a column II code to column I code 76770. 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 76775 billed for date of service August 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
22, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service September 22, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that the services are medically necessary. The Plan denied your request. The Plan says the 
enrollee must receive care from a network provider. In most cases, care that the enrollee receives from an out-
of-network provider will not be covered. The exceptions include emergency care or urgently needed services 
that you get from an out-of-network provider. If the enrollee needs medical care that Medicare requires our 
Plan to cover and the providers in our network cannot provide this care, the enrollee can get this care from an 
out-of-network provider. The enrollee must receive approval from our Plan before receiving care from an out-
of-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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) (E0652) and 
accessories (E0656, E0667). 
 
You asked the Plan to pre-approve the PCD and accessories. The Plan denied your request. The Plan says this 
is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PCD and accessories are covered for the indications 
established in the applicable LCD. 
 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 PCD and accessories. Our reviewer 
says that the requested PCD and accessories are not medically reasonable and necessary. Our physician 
reviewer found that the provided medical records do not document trial and failure of at least four weeks of 
regular, daily, multiple-hour home usage of a basic pump (E0650 or E0651) after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. 
 
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 PCD and accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a pneumatic compression device (PCD) (E0652) and accessories (E0656, E0667).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral lower extremity revascularization. 
 
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 non-coronary vascular stents are covered when 
specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee's symptoms are unclear 
from the submitted medical records. The documentation provided does not suggest severe peripheral artery 
disease and the arterial brachial indices (ABIs) are essentially normal. There is a lack of clarity with respect to 
the outcome of the enrollee's treatment on the left and what the plan is moving forward.  The documentation 
does not suggest limb threat. The criteria for coverage are not met and the services are not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bilateral lower extremity revascularization.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that on August 4, 2022 the member suffered a lumbar fracture with a subsequent fall on 
thanksgiving and the member is temporarily staying with family in Indiana while recovering from the fall. You 
say that this provider has ordered an MRI to see if the member has re-injured himself or if this is 
neuromuscular damage from the first fall. The Plan denied your request. The Plan says this service is not urgent 
or emergent care and the care is available with in-network providers. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is 
not providing these services and is not making arrangements to provide these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the requested out-of-network 
provider.
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 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. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where she is currently receiving care. All medically necessary care is being provided in the 
current acute care setting. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a car lift for a scooter (E1399). 
 
You asked the Plan to pre-approve a car lift for a scooter. You say that you have stage 3 cancer with numbness 
in both feet and hands. You cannot stand for too long or walk small distances. You say you really need this 
equipment. The Plan denied your request. The Plan says the requested lift is not medical in nature and is 
regularly and primarily used by persons who do not have a specific medical need for them. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a car lift for a scooter (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that you saw this provider about two years and have 
history with them. You say that you are having a hard time finding a primary care physician within your 
medical group that is accepting new patients. You also say that you need to see a doctor. The Plan denied your 
request. The Plan says the requested service is not urgent or emergent. The Plan also says there are in-network 
providers available. 
 
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. Additionally, the provided documentation does not support that you are in active treatment with the requested provider. Therefore, we decided that the Plan does not have to 
pre-approve an office visit (99204) 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 power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that the enrollee is private pay at this facility. 
The Plan denied your request. The Plan says a skilled nursing facility is not considered 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.  
 
The records show that a power wheelchair is being requested for use in a SNF. Based on this information, we 
decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that a lower level of care will not be sufficient or 
equipped to address the enrollee's comorbidities and allow them the opportunity to participate in needed daily 
therapy to regain prior level of functioning. The Plan denied your request. The Plan says while the enrollee will 
likely benefit from ongoing therapy to enhance their rehabilitation potential, there is no evidence that this 
cannot safely be done at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically stable and does not require multiple therapies. While the 
enrollee would benefit from physical and occupational therapy, their rehab needs can be safely met in an 
alternate and low intensity setting such as in an SNF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need aggressive rehabilitation so that you can 
return home safely. The Plan denied your request. The Plan says based on Medicare guidelines the inpatient 
rehabilitation facility services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
at an intensive rehabilitation therapy program. There is not a reasonable expectation that you 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 acute IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 9, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this claim was denied in error. 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 September 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the infusion, up to one hour (96365), infusion, 
each additional hour (96366), and vitamin C (J3490) provided from February 21, 2022, to July 19, 2022, by a 
naturopathic provider. 
 
You asked the Plan to reimburse you for the infusion services. You say that you were advised by a plan 
representative that your intravenous (IV) infusions would be covered. The Plan denied your request. The Plan 
says naturopathic services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to reimburse you for the infusion, up to one hour (96365), infusion, each additional hour (96366), and vitamin 
C (J3490) provided from February 21, 2022, to July 19, 2022, by a naturopathic provider.  
 
Your complaint about being misled by a plan representative is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with power tilt (K0856) 
any type of cushioned headrest (E0955) positioning wheelchair back cushion (E2620) electronic connection 
between wheelchair controller and one power seating system motor (E2310) power seating system, tilt only 
(E1002) manual swingaway, retractable or removable mounting hardware for joystick (E1028) group 34 sealed 
lead acid battery (E2359) power seat elevation system (E2300) LED light kit (K0108). 
 
You asked the Plan to pre-approve the power wheelchair and accessories. You say that you are appealing the 
denial because it is unreasonable. It is established that you need a power wheelchair, and the chair must raise 
and lower in order for you to perform basic activities of daily living. The Plan denied your request. The Plan 
says the enrollee does not have medical need for single power option included with K0856 group 3 power 
wheelchair. The seat elevator (E2300) and LED Light kit (K0108) does not serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
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 power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found in this case the enrollee has a neurologic disorder with functional 
deficits. The criteria for a power wheelchair are met however, the documentation does not indicate that the 
enrollee has any pressure injuries or requires intermittent catheterization of the bladder that would necessitate 
power tilt or recline. The criteria for the specifically requested power wheelchair with power tilt 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 wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair with power tilt (K0856) any type of 
cushioned headrest (E0955) positioning wheelchair back cushion (E2620) electronic connection between 
wheelchair controller and one power seating system motor (E2310) power seating system, tilt only (E1002) 
manual swingaway, retractable or removable mounting hardware for joystick (E1028) group 34 sealed lead 
acid battery (E2359) power seat elevation system (E2300) LED light kit (K0108).