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

 
We decided that the Plan does not have to pay for the electrical connection for a power wheelchair (E2311). 
 
You asked the Plan to pay for the electrical connection. The Plan denied your request. The Plan says this is not 
a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that if a wheelchair has an electrical connection 
device described by code E2310 or E2311 and if the sole function of the connection is for a power seat 
elevation or power standing feature, it will be denied as non-covered.  
 
We looked at the file and Medicare rules. Per LCA A52504, the requested electrical connect (E2311) is not 
covered for the intended use in this case. Based on this information, we decided that Medicare rules for 
coverage of the electrical connection have not been met. Therefore, we decided that the Plan does not have to 
pay for the electrical connection for a power wheelchair (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tub stool. 
 
You asked the Plan to pre-approve a tub stool. You say that you cannot stand in the shower due to thrombosis 
you suffered on your leg. You also say that you need the stool to sit and shower. The Plan denied your request. 
The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a tub stool.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) provided on 
February 22, 2022. 
 
You asked the Plan to pay for the MRI. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
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. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 9, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the MRI have not been met. Therefore, we 
decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) provided on February 22, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Foundation Pain Index (FPI) laboratory testing (0117U) 
provided on February 18, 2022. 
 
You asked the Plan to pay for FPI testing. You say that this is a covered test which should be paid. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of FPI testing have not 
been met. Therefore, we decided that the Plan does not have to pay for Foundation Pain Index (FPI) laboratory 
testing (0117U) provided on February 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xgeva. 
 
You asked the Plan to pre-approve Xgeva. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Xgeva. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of metastatic small cell lung cancer with bony involvement. The 
documentation does not support that the enrollee has tried and failed pamidronate or zoledronic acid. The 
documentation does not support that pamidronate or zoledronic acid would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xgeva.
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 52005-LT and 52005-RT billed for date of 
service January 25, 2022. 
 You asked the Plan to pay for procedure codes 52005-LT and 52005-RT. You say that you disagree with the 
denial. 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 52005 is 1. The MAI value for this code is 2. You billed 2 units each of 
code 52005-RT and 52005-LT, exceeding the MUE. Based on this information, we decided that Medicare rules 
for coverage of procedure codes 52005-LT and 52005-RT have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 52005-LT and 52005-RT billed for date of service January 25, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cochlear implant (L8691, L8694) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the cochlear implant. You say that this cochlear implant is medically 
necessary. The Plan denied your request. The Plan says there are 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 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 a cochlear 
implant (L8691, L8694) to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service July 16, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service July 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power operated vehicle (POV). 
 
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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 2 POV is denied as not medically 
necessary. 
 
We looked at the file and Medicare rules. The requested item is a Group 2 POV described by code K0807. This 
item is denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to 
pre-approve a Group 2 power operated vehicle (POV).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that facet joint injections are not medically 
necessary. The Plan denied your request. The Plan says the requested fact joint injections do not meet the 
Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 facet joint injections. Our reviewer says 
that facet joint injections are not medically necessary. Our physician reviewer found that i this case, there is 
documentation of radiculopathy. The review has determined that the requested fact joint injections do not meet the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that you are request a prior authorization with 
Gap exception for the enrollee for a MyoPro Motion G for the treatment of left upper extremity partial 
paralysis since suffering a stroke. The Plan denied your request. The Plan says this item is considered 
experimental and investigational. There is insufficient evidence of its effectiveness in those with stroke and 
hemiparesis. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G orthotic device (L8702).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency ambulance transportation from your 
home to the hospital, and back. 
 
You asked the Plan to pre-approve the non-emergency ambulance transportation. You say that you are having 
surgery. You say that you do not have anyone to help you with transport to and from the hospital. You also say 
that you need to have this surgery. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 non-emergency ambulance 
transportation have been met. Specifically, there was no documentation provided to support that the requested services would be medically necessary. Therefore, we decided that the Plan does not have to pre-approve non-
emergency ambulance transportation from your home to the hospital, and back.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the positioning cushion/pillow/wedge, any shape or size 
(E0190). 
 
You asked the Plan to pre-approve the positioning pillow. You say that you need the cushion to sit down 
because you have a lot of pain and take many medications since it is difficult for you to remain seated. The 
Plan denied your request. The Plan says this service is not covered by Medicare. 
 
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 the positioning cushion/pillow/wedge, any shape or size 
(E0190).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TheraSkin, skin substitute. 
 
You asked the Plan to pre-approve TheraSkin, skin substitute. You say that TheraSkin, skin substitute is 
medically necessary. The Plan denied your request. The Plan says TheraSkin, skin substitute does not meet the 
Plan's Medical Policy criteria. 
 
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 TheraSkin, skin substitute. Our 
reviewer says that TheraSkin, skin substitute is not considered medically reasonable and necessary. Our 
physician reviewer found that the literature states that bioengineered skin is designed to temporarily assume the 
functions of the epidermis and/or dermis until the patient's skin barrier repairs naturally or until definitive skin 
replacement can be achieved with a skin graft or cultured equivalent. In this case, the enrollee's provider is 
requesting an appeal for the denial of a bioengineered skin substitute. The provider states the enrollees wound 
continues to have exposed bone and believes the enrollee would benefit from the treatment. Due to the 
presence of exposed bone, the requested skin substitute does not meet the Plan's Medical Policy criteria. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TheraSkin, skin substitute have not been met. Therefore, we decided that the 
Plan does not have to pre-approve TheraSkin, skin substitute.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient office visit (99213) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that your provider advised you to join a weight loss 
program. You are a diabetic and you need to lose weight for health reasons. 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 visit (99213) 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 prosthesis components (L5910, L5629). 
 
You asked the Plan to pre-approve the prosthesis components. The Plan denied your request. The Plan says the 
requested items are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that when an initial below knee prosthesis (L5500) or 
a preparatory below knee prosthesis (L5510, L5520, L5530, L5540) is provided, prosthetic substitutions and/or 
additions of procedures and components are covered in accordance with the functional level assessment except 
for codes L5629, L5638, L5639, L5646, L5647, L5704, L5785, L5962, and L5980 which will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. Per L33787, code L5629 is not covered in this case. Additionally, 
code L5910, by definition is to be used with an alignable system. However, the approved system is non-
alignable, which means that code L5910 is inappropriate for this system. Based on this information, we decided 
that Medicare rules for coverage of the prosthesis components have not been met. Therefore, we decided that 
the Plan does not have to pre-approve prosthesis components (L5910, L5629).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xolair. 
 
You asked the Plan to pre-approve Xolair. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested medication is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Xolair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional non-emergent transportation rides. 
 
You asked the Plan to pre-approve 12 additional non-emergent transportation rides. You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says this benefit is limited to twelve 
(12) one-way trips maximum per calendar year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 12 one-way trips maximum per calendar year, with a 30-mile limit per 
trip trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 12 additional non-emergent transportation rides.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom sleep apnea appliance. 
 
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 covered. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
custom sleep apnea appliance.