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

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you have had a heart attack, stroke, and have a 
Human Immunodeficiency Virus (HIV) ailment, and would like to have the utility assistance. The Plan denied 
your request. The Plan says based on the information submitted, there is no documentation that you meet all 
three criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one of 
the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve the SSBCI benefits. The Plan denied your request. The Plan says based on 
the information submitted, there is no documentation that you meet all three criteria. 
 
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 SSBCI benefits have been met. 
Specifically, medical records were not provided with this case. The records show that the Plan made multiple 
attempts to obtain this information, but it was not received. Without medical records, we are unable to 
determine if you meet the criteria for coverage. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns for a bridge for teeth number 10 and 13 
(D6751 x 2) and pontics for a bridge for teeth number 11 and 12 (D6240 x 2). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the 
requested dental items. 
 
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 these dental 
items when the services are medically necessary and reasonable.  
 
 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 dental items. Our reviewer says 
that the enrollee does not meet criteria for coverage of the requested dental items. Our physician reviewer 
found that the documentation does not support the need for the requested bridge from teeth number 10 to 13. 
The number 10 abutment has less than 50% bone remaining and is a poor abutment choice. The tooth number 
13 abutment has about 70% bone remaining and the entire bridge would be under-supported due to a lack of 
bone support. The bridge would not be medically necessary. The Plan allows for bridges in limited 
circumstances. Only one anterior tooth can be replaced with a bridge if there are no missing posterior teeth. In 
this case, there are multiple missing posterior teeth including 1,2,3,6,11,12,14,15 and 16. Given the Plan 
limitations, a bridge for teeth number 10 to 13, which would include the pontics for teeth number 11 and 12,  
would not meet the Plans criteria due to the multiple missing posterior teeth in the arch. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of these dental items have not been met. Therefore, we decided that the Plan does 
not have to pre-approve retainer crowns for a bridge for teeth number 10 and 13 (D6751 x 2) and pontics for a 
bridge for teeth number 11 and 12 (D6240 x 2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair and accessories. 
 
You asked the Plan to pre-approve the power wheelchair and accessories. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says that the power wheelchair and accessories 
are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the power 
mobility evaluation and clinical documentation is insufficient in terms of the enrollees current level of 
mobility and ability to perform transfers and daily activities of daily living. Without this information, it cannot be determined if the requested group power wheelchair is appropriate and medically necessary for the enrollee. 
Additionally, the enrollee does not have a diagnosis, impaired sensation, or a history of skin breakdown that 
would necessitate a power wheelchair with power tilt. 
 
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 2 power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the PT services. You say that you had two falls while in Florida and would 
like to continue PT services. The Plan denied your request. The Plan says 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 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 provider at issue in this case is not a network provider with the Plan. 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 PT services. Our reviewer says that the records do not indicate that the 
care provided was medically necessary. Our physician reviewer found you are currently stable, and this would 
not be considered an emergent or urgent service. 
 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 PT services have not been met.  
 
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 the PT services. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy (PT) services 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 the Kit Actuator Linak (E1399). 
 
You asked the Plan to pre-approve the Kit Actuator Linak. You say that the enrollee needs this immediately 
due to having a spinal cord injury, quadriplegia and severe morbid obesity. The Plan denied your request. The 
Plan says this item is not primarily and customarily used to service a medical purpose. 
 
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. Review of the 
Link website shows actuators are used for a variety of purposes, including industrial, agricultural, construction, 
energy, and marine. Therefore, we decided that the Plan does not have to pre-approve the Kit Actuator Linak 
(E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) testing (0037U) provided on 
March 30, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this test was medically necessary and reasonable. 
The Plan denied your request. The Plan says there is insufficient information to support the necessity of this 
test. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of F1CDx testing have been met. 
Specifically, the physician order for this test is not signed, and there are no progress notes or medical records 
from the referring physician to support the medical necessity and intent for this test. Therefore, we decided that 
the Plan does not have to pay for FoundationOne CDx (F1CDx) testing (0037U) provided on March 30, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for physician's services provided on April 22, 2022. 
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that this service does not meet the coverage requirements in the 
applicable Local Coverage Determination (LCD) or National Coverage Determination (NCD). Related services 
performed in connection with the denied procedure are also not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a Medicare rule or a Plan rule to 
substantiate their denial. Therefore, we decided that the Plan has to pay for physician's services provided on 
April 22, 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 pay for procedure code(s) 85060 billed for date of service November 
7, 2022. 
 
You asked the Plan to pay for procedure code(s) 85060. You say that this procedure was rendered in an 
appropriate place of service. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 85060. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 85060. Based on this information, 
we decided that Medicare rules for coverage of procedure code 85060 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service November 7, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0657). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that please extend 
every possible consideration to this enrollee and provide the highest possible reimbursement for this service. 
The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced 
lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either 
E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the 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. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliance (E0657).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral talking thermometer. 
 
You asked the Plan to pre-approve these services. You say that you need the thermometer because you are 
legally blind. The Plan denied your request. The Plan says the services are not covered. 
 
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 an oral talking thermometer.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service October 27, 
2022. 
 
You asked the Plan to pay for procedure code 86077. You say that these services were necessary and are 
supported as billed. 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 86077 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 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service October 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) coded E0675 and 
half leg appliance coded E0673 billed for July 12, 2022. 
 
You asked the Plan to pay for 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 claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Given that the E0675 PCD is not covered, the half leg 
appliance billed with code E0673 is also not covered. Therefore, we decided that the Plan does not have to pay 
for the pneumatic compression device (PCD) coded E0675 and half leg appliance coded E0673 billed for July 
12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81455) provided on October 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that this test was necessary and is supported in the 
medical record. 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 (81455) provided on October 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve these services. You say that the tanks provided by the Plan are too heavy to 
carry. The Plan denied your request. The Plan says duplicate items are not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have an oxygen concentrator with portable tanks. The requested portable oxygen 
concentrator serves the same purpose as your current equipment. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4595 billed for date of service October 9, 
2022. 
 
You asked the Plan to pay for procedure code A4595. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4595 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code A4595 is statutorily excluded from Medicare payment. Based on this information, we decided 
that Medicare rules for coverage of procedure code A4595 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code A4595 billed for date of service October 9, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 
necessary. 
 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the use of proton therapy is an accepted radiation technology, that has proven efficacy and 
tolerability. Proton therapy is not investigational- it is simply a different means to deliver radiation. Thus, the 
need for proton therapy for advanced lung cancer needs to be established an on individual basis with a plausible rationale as to why proton therapy is needed in lieu of more standard 3D conformal radiation or 
intensity-modulated. For this patient with a large central tumor, it is plausible that the heart would receive high 
doses and that proton therapy could reduce exposures. This request would be within accepted standards of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-
approve proton beam therapy.  
 
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.