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

 
We decided that the Plan has to pre-approve an ankle (L5986) for a lower-limb prosthesis. 
 
You asked the Plan to pre-approve a prosthetic ankle. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says that the requested item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a lower limb prosthesis is covered when the 
beneficiary: 
1. Will reach or maintain a defined functional state within a reasonable period of time; and 
2. Is motivated to ambulate. 
 
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 prosthetic ankle. Our reviewer says 
that a prosthetic ankle is medically reasonable and necessary in this case. Our physician reviewer found that the 
treating physician's and prosthetist's supporting documentation corroborate that the enrollee is a successful K3 
functional level. The enrollee's current foot is over 3 years old and is delaminating, creating a safety and 
functional concern. The enrollee meets coverage criteria for the requested item. 
 
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 prosthetic ankle have been met. Therefore, we decided that the Plan has to 
pre-approve an ankle (L5986) for a lower-limb prosthesis.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on June 23, 2023. 
 
You asked the Plan to pay for physical therapy services. You say that these services were medically necessary. 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 physical therapy services provided on June 23, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service April 22, 
2023. 
 
You asked the Plan to pay for the billed code. You say that supporting documentation was provided. The Plan 
denied your request. The Plan says the service at issue was not billed with the required modifier to allow 
separate payment within the global surgery period.  
The Plan must follow Medicare rules. Medicare rules say that EM services unrelated to the surgical procedure, 
which should be billed with modifier -24, and unrelated surgical procedures, which should be billed with 
modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 27840 
provided on March 19, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99284 billed for 
date of service April 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 16, 2022. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 office visit provided on November 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 27, 2023. 
 
You asked the Plan to pay for an office visit. You say that there should not be a referral needed for this service. 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 an office visit provided on June 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81443). 
 
You asked the Plan to pre-approve the genetic testing. You say that the testing is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that molecular pathology procedures (Tier1 and Tier 2) 
may be eligible for coverage when testing assay(s) are Food and Drug Administration (FDA) approved/cleared, 
or if documentation supports analytical validity and clinical utility; AND the results of the testing must directly 
impact treatment or management of the Medicare beneficiary. 
 
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 genetic testing. Our reviewer says 
that the genetic testing is not medically necessary. Our physician reviewer found a review of the clinical 
records does not show how this testing will directly impact treatment and management. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve genetic testing (81443).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on August 21, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the appropriate 
documents needed for payment. The Plan denied your request. The Plan says the documentation requirements 
have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. The proof of delivery provided does not have the 
enrollees signature. 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 diabetic supplies 
provided on August 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on July 11, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided all the 
required documents and would like the claim processed. The Plan denied your request. The Plan says the 
documentation requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
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 supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on July 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retainer crowns porcelain/ceramic (D6740) provided on July 
25, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 $6,000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for retainer crowns porcelain/ceramic (D6740) provided on July 25, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing billed for date of service September 23, 2023. 
 
You asked the Plan to pay for the lab testing. You say that the codes are payable together. The Plan denied your 
request. The Plan says that both codes were billed with the -59 modifier. 
 
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 88365 is a column II code to column I code 88321. Code 88365 has 
been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have been met. The file shows that column I code 88321 has already been paid by the Plan. As such, 
there is no need for a coverage decision. Therefore, we decided that the Plan has to pay for the lab testing billed 
for date of service September 23, 2023.  
 
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 an advanced knee for a lower-limb prosthesis. 
 
You asked the Plan to pre-approve an advanced knee. You say that the request is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested advanced knee 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 an advanced knee. Our reviewer says 
that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the treating physicians documentation does not provide sufficient support justification for 
a microprocessor knee. There is no narrative evident in the case record on the enrollees activities of daily 
living (ADLs), other activities or a rationale why a microprocessor knee is necessary. The treating physicians 
documentation does not state functional level or corroborate the prosthetist's notes. 
 
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 advanced knee have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an advanced knee for a lower-limb prosthesis.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound provided on August 29, 2023. 
 
You asked the Plan to pay for the ultrasound. You say that you are requesting reconsideration of the denied 
claim. 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 Plan had network providers available who were capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 ultrasound provided on August 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on 
July 28, 2023.  
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as the rendering provider is not 
enrolled with Medicare. 
 
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. 
 
 
  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 a continuous glucose monitor (CGM) 
(A4239) provided on July 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
provided on July 26, 2023. 
 
You asked the Plan to waive the copayment for the computed tomography (CT) scan. You say that you have 
never been charged such a high amount for a scan. 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 $200 
copayment for in-network outpatient diagnostic tests, including CT scans. 
 
You have been asked to pay a $200 copayment for the computed tomography (CT) scan. This item/service falls 
within the in-network outpatient diagnostic tests, including CT scans 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 the computed tomography (CT) scan provided on July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20930 billed for date of service July 18, 
2023. 
 
You asked the Plan to pay for procedure code 20930. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says procedure code 20930 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 20930 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20930 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20930 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20930 billed for date of service July 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildups, including any pins when required  
(D2950 x 2) provided on March 2, 2023. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the dental items provided are not covered under the 
supplemental dental policy.  
 
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 dental items provided are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildups, including any pins when required (D2950 x 2) provided on March 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service May 20, 
2023. 
 
You asked the Plan to pay for the billed testing. You say that the services should be paid separately. The Plan 
denied your request. The Plan says duplicate testing is not covered. 
 
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 the rules. The medical records show that a Hematology Profile Plus test was 
provided. This is a covered test. The claim shows that this test was billed with codes 81455 and 81456. Billing 
guidelines require covered molecular diagnostic tests to be billed with one code and one unit of service. Based 
on this information, we decided that Medicare rules for coverage of the billed testing have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 81456 billed for date of service 
May 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rear basket. 
 
You asked the Plan to pre-approve a rear basket. You say that the enrollee's weight is within 5% of the 
minimum weight capacity for this wheelchair. You also say that it is reasonable that the enrollee would gain 
that 5%. The Plan denied your request. The Plan says this item does not serve a primary medical purpose and 
therefore is 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 a rear basket.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing (G0299 x8), home health 
physical therapy (G0151 x15), and home health occupational therapy (G0152 x12). 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is 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 services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that you have 
not been recently hospitalized. You do not require wound care, catheterization, tube feeding, or administration 
of complex medications. You are receiving intravenous (IV) hydration as needed for dehydration likely due to 
poor oral intake. Palliative care documentation dated December 18, 2023, indicated that your family verbalized 
that you would not want a feeding tube. IV access is noted to be difficult and is showing decreased benefit. 
You are noted to be lethargic. It is understandable that you are at high risk for poor oral intake and consuming 
fluids, but continued IV hydration in the home is not a long-term plan and there should be assessment in terms 
of placement of a G-tube if indicated and/or desired. Palliative care has been consulted and continued IV 
hydration is noted to be of decreasing benefit. Your family is providing 24-hour assistance and has been 
educated in terms of medication management. You were presumed to have had another stroke but there is no 
definitive diagnosis or imaging provided. You are noted to have had a decline in function and require 
significant assistance with mobility and daily activities. There is a lack of documentation indicating that you 
can actively participate in therapy now. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing (G0299 x8), home health physical therapy (G0151 
x15), and home health occupational therapy (G0152 x12).