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

 
We decided that the Plan has to pay for the electrodes (A4595) provided on October 4, 2022. 
 
You asked the Plan to pay for the supplies. You say that the billed code is an accepted procedure code 
according to the enrollee's Plan billing guidelines and policy. The Plan denied your request. The Plan says that 
the provided proof of delivery is not valid. 
 
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 contains a valid proof of deliver for the supplies provided in this case. Therefore, we decided that 
the Plan has to pay for the electrodes (A4595) provided on October 4, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) purchased on February 18, 2021. 
 
You asked the Plan to pay for the frames. You say that you are in need of a good pair of eyeglasses and need 
the funds to get them. You also say that the providers the Plan uses have damaged frames, and use second class 
materials which is not acceptable. The Plan denied your request. The Plan says your reimbursement request 
was submitted on April 11, 2022, and the date of service requested is February 18,2021. The Plan also says this 
is past the 12-month filing limit period required by the Plan. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the frames was not filed until April 11, 2022. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for the frames (V2020) purchased on February 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visits (99213) provided from February 
11, 2022 to August 19, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient office visits. You say that you consulted with the medical office 
and the doctor included their signature, license number, and National Provider Identifier (NPI) on the receipts. 
The Plan denied your request. The Plan says the provider that gave the services is not contracted and did not 
pre-authorize. The Plan also says there was no evidence of medical emergency nor life at risk or in jeopardy. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The records show that the treating 
provider is OON, and the services were not pre-authorized by the Plan. We found no exception that would 
require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for 
the outpatient office visits (99213) provided from February 11, 2022 to August 19, 2022, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 
15, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 15, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for knee arthroscopy (procedure code 29876) rendered on September 6, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the denied code is not supported in the records submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 29876 is "Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or 
lateral)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the procedure detail cites 
synovectomies were performed at the patellofemoral joint, medial femoral condyle, the intercondylar notch, 
and in the lateral compartment. Therefore, the records do support that CPT 29876: arthroscopy, knee, surgical, 
synovectomy, major 2 or more compartments (e.g., medial or lateral) was rendered in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
knee arthroscopy (procedure code 29876) rendered on September 6, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device (E0730) provided on October 15, 2022. 
 
You asked the Plan to pay for the TENS device. You say that the device was billed correctly. The Plan denied 
your request. The Plan says the documentation does not support the billed supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid proof of delivery the supplies provided in this case. Specifically, the proof 
of delivery provided is for a different date of service. 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 the transcutaneous electrical nerve stimulation (TENS) device (E0730) provided on October 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you are having back problems, compression 
nerve 15 vertebra, and it is causing you muscle problems on the bladder. The Plan denied your request. The 
Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Zinger motorized scooter. 
 
You asked the Plan to pre-approve a motorized scooter. You say that the requested scooter is medically 
necessary. The Plan denied your request. The Plan says that a valid face-to-face encounter has not been 
performed. 
 
The Plan must follow Medicare rules. Medicare rules say that a face-to-face encounter must be conducted 
within six months. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a motorized scooter have not been met. Specifically, the record does not show a valid face-to-face 
encounter has been performed. Therefore, we decided that the Plan does not have to pre-approve a Zinger 
motorized scooter.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for injection procedure; radioactive tracer for identification of sentinel 
node rendered on October 7, 2022. 
 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 38792 is "Injection procedure; radioactive tracer for identification of sentinel node." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found CPT code 38792 is supported by the 
medical record. The procedure report states that radioactive dye was injected. CPT coding instructions for code 
38900 state if radioactive dye is injected, 38792 should be reported. In this case, 38792 is supported and 38900 
is not so 38792 cannot be included in a procedure that was not performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
injection procedure; radioactive tracer for identification of sentinel node rendered on October 7, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0849). 
 
You asked the Plan to pre-approve a group 3 power wheelchair (K0849). You say that the requested group 3 
power wheelchair (K0849) is medically necessary. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for a group 3 power wheelchair (K0849). 
 
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 a group 3 power wheelchair (K0849). 
Our reviewer says that the enrollee does not meet criteria for a group 3 power wheelchair (K0849). Our 
physician reviewer found the enrollee has chronic pain and limited ambulation. He is able to walk 150 feet 
contact guard assist and is modified independent level for transfers. No high risk for skin breakdown, no 
catheter, no spasticity. Per L33789 the diagnostic, functional, and clinical criteria for a group 3 power 
wheelchair are 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 a group 3 power wheelchair (K0849) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 power wheelchair (K0849).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre Kit 2 Sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre Kit 2 Sensor. The Plan denied your request. The Plan 
says the enrollee does not require insulin three or more times daily. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the a FreeStyle Libre Kit 2 Sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a FreeStyle Libre Kit 2 Sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811) provided on 
November 28, 2022. 
 
You asked the Plan to pay 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 these services are not payable as they were 
rendered by an ineligible provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the acupuncture treatments  
(97810, 97811) provided on November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary overdenture (D5863) and a 
complete mandibular overdenture (D5865). 
 
You asked the Plan to pre-approve the overdentures. You say that the enrollee called the Plan and was told that 
dental codes D5863 and D5865 are on the list. You say you then proceeded to change the enrollee to this Plan. 
The Plan denied your request. The Plan says overdentures (D5863 and D5865) are not covered benefits. 
 
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 
complete maxillary overdenture (D5863) and a complete mandibular overdenture (D5865).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan (procedure code 93971) rendered on 
September 13, 2022. 
 
You asked the Plan to pay for the scan. You say that this should be paid for. The Plan denied your request. The 
Plan says Current Procedural Terminology (CPT) code 93971-RT-59 (1 Unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 93971 is "Duplex scan of extremity veins including 
responses to compression and other maneuvers; unilateral or limited study." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the scan. Our reviewer says that the services at issue in this case were not supported. Our reviewer found that the enrollee had ultrasound-guided therapy of the right 
greater saphenous vein on September 13, 2022. Right lower extremity ultrasound was done and used as a 
roadmap for the sclerotherapy. As such, Medicare does not allow billing for a separate procedure when the 
ultrasound was done for the purpose of roadmapping as shown in the operative report. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the scan have not been met. Therefore, we decided that the Plan does not have 
to pay for a duplex scan (procedure code 93971) rendered on September 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93458 & 99152 billed for date of service 
August 29, 2022. 
 You asked the Plan to pay for procedure codes 93458 & 99152. You say that this service was medically 
necessary. The Plan denied your request. The Plan says payment for code 93458 is bundled into payment for 
code 92928. Records do not support code 99152. 
 
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 93458 
is a column II code to column I code 92928. This claim has not been billed with an appropriate modifier to 
bypass the edit. Code 99152 is not supported in the provided records as they do not show the presence of a 
trained observer. 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 codes 93458 & 99152 billed for date of service August 
29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services billed for dates of service May 19, 
2021, to June 3, 2021. 
 You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says a plan of care 
was not submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The records provided do not include a plan of care from the enrollees 
physician. Based on this information, we decided that Medicare rules for coverage of the billed services have 
not been met. Therefore, we decided that the Plan does not have to pay for the home health services billed for 
dates of service May 19, 2021, to June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve the dental service. You say that you never received any dentures or approval 
from the Plan. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of July 13, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473). 
 
 
You asked the Plan to pre-approve removal of torus mandibularis. You say that this should be covered. The 
Plan denied your request. The Plan says this is not a covered service. 
 
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 
removal of torus mandibularis (D7473).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cequa. 
 
You asked the Plan to pre-approve Cequa. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says Cequa is not covered under the enrollee's Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cequa.   
Benefits for Cequa may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam (D0367). 
 
You asked the Plan to pre-approve the dental service. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because the cone beam is not covered by the Plan. 
 
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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
cone beam (D0367).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical orthosis (L0180) provided on December 1, 2022. 
 
You asked the Plan to pay for the orthosis. You say that the medical records indicate the enrollee has a history 
of chronic neck pain. You also say that this should be reprocessed and paid. The Plan denied your request. The 
Plan says the provided documentation does not support the billed supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the cervical orthosis (L0180) 
provided on December 1, 2022.