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

 
We decided that the Plan does not have to pre-approve electrical connection between the wheelchair controller 
and two or more motors (E2311) expandable controller (E2377) and harness (E2313). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that you request that the denial be 
reconsidered and the power wheelchair with a power tilt and recline seating system be approved so you can 
provide the enrollee with the appropriate medical equipment to meet their medical needs. The Plan denied your 
request. The Plan says the upgraded electronics are not medically necessary as there is not a medical need to 
control these power options through the joystick.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has paraplegia and is able to feed themself and groom and dress themself 
and uses their upper body independently. The upgraded electronics are not medically necessary as the enrollee 
has adequate strength to manage the standard power drives.  
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electrical connection between the wheelchair controller and two or more motors 
(E2311) expandable controller (E2377) and harness (E2313).
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 the enrollee has been referred by their 
family practice physician for myoelectric orthotic restoration, using the MyoPro Motion G. The Plan denied 
your request. The Plan says this is considered experimental and investigational due to insufficient evidence of 
safety and efficacy. 
 
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. There are not enough studies to show MyoPro is safe and effective to 
help the enrollee recover from their disability. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0656). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that an advanced 
PCD was prescribed over a basic mode due to complications of the enrollee's clinical presentation. 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 (E0656).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes G0483 and 80307 for date of service May 16, 2023. 
 
You asked the Plan to pay for codes G0483 and 80307. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says he services billed are 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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
The CPT Code Manual definition of code 80307 is drug test(s), presumptive, any number of drug classes, any 
number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, 
ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with 
or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, 
TOF) includes sample validation when performed, per date of service. 
 
We find that CPT codes G0483 and 80307 are not supported in the medical record. Specifically, the submitted 
medical records do not include definitive results of 22 or more drug classes; therefore, code G0483 is not 
supported. The submitted medical records do not include laboratory results for drug test, presumptive, any 
number of drug classes, any number of devices or procedures; by instrument chemistry analyzers, 
chromatography, and mass spectrometry either with or without chromatography, includes sample validation 
when performed; therefore, code 80307 is not supported. Based on this information, we decided that Medicare 
rules for coverage of codes G0483 and 80307 have not been met. Therefore, we decided that the Plan does not 
have to pay for codes G0483 and 80307 for date of service May 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nerve block procedure provided on July 
28, 2023. 
 
You asked the Plan to waive the copayment for a nerve block procedure. You say that you were never told 
there would be such a large copayment for this procedure. You had this done before and it didnt cost this 
much. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $345 
copayment for outpatient surgery/surgical procedures, includingservices provided at hospital outpatient 
facilities and ambulatory surgical centers.  
You have been asked to pay a $345 copayment for a nerve block procedure. This item/service falls within the 
outpatient surgery/surgical procedures, includingservices provided at hospital outpatient facilities and 
ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a nerve 
block procedure provided on July 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee extension assist (L5850). 
 
You asked the Plan to pre-approve a knee extension assist. You say that you are requesting reconsideration of 
the denied items. The Plan denied your request. The Plan says the requested knee extension is unbundled. 
 
The Plan must follow Medicare rules. Medicare rules say that code L5850 is an additional feature and/or 
function that do not describe a complete endoskeletal knee-shin system.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a knee extension assist have not been met. Specifically, a knee extension assist is not part of the 
requested knee and is unbundled. Procedure code, L5850, is excluded from the proper coding of an Otto Bock 
C-leg. Therefore, we decided that the Plan does not have to pre-approve a knee extension assist (L5850).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 27, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81479 and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that please find the attached appeal and 
process the claim towards payment. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
July 27, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81335, 81479 and 81238.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on July 25, 
2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that this service should be fully 
covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $20 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist office visit provided on July 25, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy provided on August 03, 2023. 
 
You asked the Plan to pay for the colonoscopy. You say that you are asking for the medical records to be 
reviewed. The Plan denied your request. The Plan says that 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the colonoscopy 
provided on August 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit provided on March 27, 2023. 
 
You asked the Plan to pay for a new patient office visit. You say that this service should be covered. The Plan 
denied your request. The Plan says that 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a new patient office visit 
provided on March 27, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance services received on May 25, 
2023. 
 
You asked the Plan to pay for the non-emergent ambulance services. You say that you do not feel the charges 
should be your responsibility. The Plan denied your request. The Plan says there are no clinical records to 
support the medical necessity of the service. 
 
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 the non-emergent ambulance services 
have been met. There are no medical records to determine if the services were medically necessary. Therefore, 
we decided that the Plan does not have to pay for the non-emergent ambulance services received on May 25, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection (SIJI). 
 
You asked the Plan to pre-approve a SIJI. You say that the requested procedure is medically necessary to treat 
the enrollee. The Plan denied your request. The Plan says the procedure requested does not meet the criteria 
necessary for approval. 
 
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 SIJI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided, there is no sacroiliac (SI) joint instability, fracture or 
lesion and no clinical physical exam evidence of SI dysfunction. Therefore, the SIJI requested is not supported. 
 
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 SIJI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a sacroiliac joint injection (SIJI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220 and D0230) and a limited oral 
evaluation (D0140), provided on August 1, 2023. 
 
You asked the Plan to pay for D0220, D0230, and D0140. You say that this dental work was needed after you 
fell. The Plan denied your request. The Plan says the rendered dental services 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 pay for intraoral 
imaging (D0220 and D0230) and a limited oral evaluation (D0140), provided on August 1, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for a specialist office visit and the x-ray 
provided on August 15, 2023. 
 
You asked the Plan to reduce the copayments for a specialist office visit and the x-ray. You say that you should 
only have a $25 copayment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for each covered specialist office visit. Your contract with the Plan clearly says that you must pay a 
$15 copayment for each covered x-ray in a provider's office. 
 
You have been asked to pay a $25 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits benefit category. You have also been asked to 
pay a $15 copayment for the x-ray. This item/service falls within the outpatient diagnostic tests and therapeutic 
services and supplies benefit category. You have been asked to pay a total of $40 ($25 copayment + $15 
copayment = $40). This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to reduce the copayments for a specialist office visit and the 
x-ray provided on August 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on Januaary 12, 2023. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not covered as a 
screening test. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the testing provided 
on Januaary 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an acute inpatient stay provided on May 16, 
2023, to May 26, 2023. 
 
You asked the Plan to waive the copayment for an acute inpatient stay. You say that you should not have all 
these copayments. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for inpatient hospital stay. 
 
You have been asked to pay a $50 copayment for an acute inpatient stay. This item/service falls within the inpatient hospital stay benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. You have been asked to pay a total of $400 for the inpatient hospital stay ($200 copayment 
+ $200 = $400). You have not been charged for the day you were discharged. Therefore, we decided that the 
Plan does not have to waive the copayment for an acute inpatient stay provided on May 16, 2023, to May 26, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 22 home health skilled nursing visits.  

You asked the Plan to pre-approve 22 home health skilled nursing visits. You say that you would like to 
request reconsideration of the denied home health services and that the services requested are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health skilled nursing visits. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found based 
on the documentation provided, the daily HH SN services are not medically necessary, reasonable or coverable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 22 home health skilled nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heel lift.  
 
You asked the Plan to pre-approve a heel lift. You say that you would like the Plan to reconsider their denial. 
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 a heel lift.