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

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller 
(E2377), expandable controller harness (E2313), joystick control Q-Logic 3 (K0108), and adjustable height 
joystick mount (K0108). 
 
You asked the Plan to pre-approve an electronic connection, expandable controller, expandable controller 
harness, joystick control Q-Logic 3, and adjustable height joystick mount. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. The joystick and joystick mount are unbundled. 
 
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 an electronic connection, expandable 
controller, expandable controller harness, joystick control Q-Logic 3, and adjustable height joystick mount. 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 adequate upper body strength to manage 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 an electronic connection, expandable controller, expandable controller harness, 
joystick control Q-Logic 3, and adjustable height joystick mount have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an electronic connection (E2311), expandable controller (E2377), 
expandable controller harness (E2313), joystick control Q-Logic 3 (K0108), and adjustable height joystick 
mount (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablations (RFAs, 6 additional units).  
You asked the Plan to pre-approve RFAs. You say that the enrollee had successful RFA treatment in the past. 
The Plan denied your request. The Plan says with the Plan's approval the enrollee has had more than 2 RFA 
sessions with 12 rolling months. 
 
The Plan follows Medicare rules. Medicare rules state that facet joint interventions such as RFA may be 
covered under certain conditions. 
 
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 RFAs. Our reviewer says that the 
enrollee does not meet criteria for these additional RFAs. Our physician reviewer found Medicare limits the 
number of levels to 2 levels bilaterally per session. It has been 11 months since the last RFA session. Only 2 
levels are deemed reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFAs have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablations (RFAs, 6 additional units).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 months continued use of home ventilator, any type, 
used with non-invasive interface (E0466). 
 
You asked the Plan to pre-approve continued use of ventilator. You say that you need this machine to sleep as 
it helps remove the carbon dioxide from your blood and it also helps with headaches.  The Plan denied your 
request. The Plan says the request to continue using a device to assist with breathing (noninvasive ventilator or 
NIV) coded as E0466 does not meet the requirements for approval for an additional 9 months.  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 continued use of ventilator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this enrollee has COPD and obesity hypoventilation syndrome and has had 
a home ventilator for an unknown duration. A recent device download shows good compliance with use of the 
device. The original documentation supporting approval of the device is not provided. There are no pulmonary 
function tests to assess the severity of the COPD. There is no documentation of chronic carbon dioxide (CO2) 
retention with an arterial blood gas analysis (ABG) done while stable. The records do not show that the 
enrollee has been tried on BiPAP with average volume assured pressure support (AVAPS) as an outpatient. 
Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. The plan 
has approved the current device for 3 months, which allows time for transition to BiPAP. Continuation of the 
home ventilator is not medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued use of ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 9 months continued use of home ventilator, any type, used with non-invasive 
interface (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve backrest options, 8 Deg with Push Handles, other 
accessories (K0108). 
 
You asked the Plan to pre-approve wheelchair accessory. You say that the enrollee requires the use of the 
optimally configured manual wheelchair on the days she cannot tolerate her prosthesis. The Plan denied your 
request. The Plan says the requested push handles do not primarily serve a medical purpose. The fold down 
push handles is for someone to push the enrollee. This enrollee is able to self-propel a wheelchair. 
 
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 backrest options, 8 Deg with Push Handles, other 
accessories (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing codes 81226, 81240, 81241, and 81328 billed for 
date of service February 1, 2023. 
 
You asked the Plan to pay for the billed services. You say that the treatment sought was medically necessary. 
The Plan denied your request. The Plan says there is insufficient information to corroborate the services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. The panel testing that was not billed with a single panel code as 
required. 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 lab testing codes 81226, 81240, 81241, 
and 81328 billed for date of service February 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a multi-axial rotation unit (L5986). 
 
You asked the Plan to pre-approve the multi-axial rotation unit. You say that the enrollee has been an amputee 
for some time now. You also say that the enrollee is at a K3 level and is still working a full-time job. The Plan 
denied your request. The Plan says the documentation does not support the need of a rotational unit. 
 
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 multi-axial rotation unit. Our 
reviewer says that the requested multi-axial rotational unit is not medically necessary. Our physician reviewer 
found a level 3 ambulator has the ability or potential for ambulation with variable cadence. Typical of the 
community ambulator who has the ability to traverse most environmental barriers and may have vocational, 
therapeutic or exercise activity that demands prosthetic utilization beyond simple locomotion. The reviewer 
found that the requested multi-axial rotation unit is not a complete unit and is intended for a K3 functional 
level. The reviewer found that the documentation does not support that the enrollee is able to ambulate at a K3 
functional level. There is no clear documentation to support the enrollee requires the requested multi-axial 
rotational unit. Therefore, the reviewer found that the multi-axial rotational unit is not medically reasonable or 
necessary. 
 
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 multi-axial rotation unit have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a multi-axial rotation unit (L5986).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the microsurgical techniques, requiring use of operating 
microscope (69990). 
 
You asked the Plan to pre-approve the service. You say that the enrollee is experiencing pain running down the 
lumbar spine. The Plan denied your request. The Plan says the service is not covered with the codes that are 
being requested. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Medicare guidance says use of a 
surgical microscope cannot be billed for separately in this type of surgery. Therefore, we decided that the Plan 
does not have to pre-approve the microsurgical techniques, requiring use of operating microscope (69990).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve reinsertion of spinal fixation device (22849). 
 
You asked the Plan to pre-approve reinsertion of spinal fixation device. You say that this is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet 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 reinsertion of spinal fixation device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this is extensive multilevel revision surgery in the lumbar spine. The 
reinsertion code is already included in the osteotomy and fusion codes for the surgery. It cannot be unbundled. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of reinsertion of spinal fixation device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve reinsertion of spinal fixation device (22849).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing codes 81225, 81227, 81231, and 81232 
provided on December 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that the treatment sought was medically necessary. The 
Plan denied your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. The panel testing was not billed with a single 
code as required. Based on this information, we decided that Medicare rules for coverage of the lab services 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing codes 81225, 
81227, 81231, and 81232 provided on December 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmic diagnostic imaging (92134) and a determination 
of refractive state (92015) provided on February 16, 2023 
 
You asked the Plan to pay for ophthalmic diagnostic imaging (92134) and a determination of refractive state 
(92015). You say that you are appealing with supporting records. The Plan denied your request. The Plan says 
Original Medicare does not cover routine eye examinations for eyeglasses contacts. Fundus photography does 
not meet the requirements for coverage. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a determination of refractive state when they are part of a routine eye examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers one routine eye 
examinations/refractions per calendar year. Medical/diagnostic eye refractions and fundus photography is 
excluded from this benefit. Based on this information, we decided that the Plan's rules for coverage of 
ophthalmic diagnostic imaging (92134) and a determination of refractive state (92015) have not been met. 
Therefore, we decided that the Plan does not have to pay for ophthalmic diagnostic imaging (92134) and a 
determination of refractive state (92015) provided on February 16, 2023
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup services (D2950 x2). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 core 
buildup services (D2950 x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date of service 
December 21, 2022.  
 
You asked the Plan to pay for code 83789. The Plan denied your request. The Plan says code 83789 is not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. We find that the testing described by code 83789 is not separately 
payable. Based on this information, we decided that Medicare rules for coverage of code 83789 have not been 
met. Therefore, we decided that the Plan does not have to pay for validity testing billed with code 83789 for 
date of service December 21, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you are improving but continue to need a 
walker and experience pain.  The Plan denied your request. The Plan says the remaining physical therapy visits 
are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that you have previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of your 
medical condition. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, vacuum pump, 
residual limb volume management and moisture evacuation system (L5781). 
 
You asked the Plan to pre-approve a vacuum assisted socket system (VASS). You say that without the 
requested socket, the enrollee would not be able to walk and would need a new prosthetic. The Plan denied 
your request. The Plan says the requested vacuum socket is experimental and cannot be approved. 
 
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 vacuum assisted socket system 
(VASS). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the use of an L5781 vacuum assisted suspension 
system for residual limb volume management and moisture evacuation systems among lower extremity 
amputees is unproven and not medically necessary due to insufficient evidence of safety and/or efficacy. The 
requested is not medically necessary per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), 
as Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or 
treatment of illness or injury or to improve the functioning of a malformed body member. 
 
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 vacuum assisted socket system (VASS) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, vacuum pump, residual 
limb volume management and moisture evacuation system (L5781).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic - porcelain/ceramic (D6245) for tooth number 
10 
 
You asked the Plan to pre-approve a pontic - porcelain/ceramic (D6245) for tooth number 10. You say that you 
are appealing with supporting records. The Plan denied your request. The Plan says this service is not a covered 
expense under your dental 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
pontic - porcelain/ceramic (D6245) for tooth number 10
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a protective outer-surface covering system (L5962). 
 
You asked the Plan to pre-approve a protective outer-surface covering system. You say that the requested item 
is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested item is not 
medically necessary. 
 
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 protective outer-surface covering system. Our reviewer says that the requested item is not considered medically reasonable and necessary in this 
case. Our physician reviewer found that no justification or context is found in the record provided to suggest 
that the enrollee's prosthesis will be exposed to unusually harsh environments necessitating additional 
protection beyond what is provided with a typical cover. 
 
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 protective outer-surface covering system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a protective outer-surface covering system (L5962).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on August 16, 2022.  
 
You asked the Plan to pay for the dental services represented by codes D0140, D0120 and D1110. The Plan 
denied your request. The Plan says your benefit for the limited oral evaluation - problem focused  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 Plan's 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 limited oral evaluation - problem focused was exhausted on date of service May 23, 
2022. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem 
focused provided on August 16, 2022.