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

 
We decided that the Plan does not have to pre-approve the flex walk system (L5981), multi-axial rotation unit 
(L5986), shock reducing pylon feature (L5988), axial rotation unit adjustment (L5984), and disartic alignable 
system (L5920). 
 You asked the Plan to pre-approve the prosthesis with an advanced foot and alignable system. You say that the 
items are medically necessary. The Plan denied your request. The Plan says the enrollee's current foot is less 
than 36 months old, and therefore still under warranty. Medicare does not cover replacement costs for items 
still under warranty. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement when the equipment is under warranty is not covered.  
 
The item being requested shows to be for replacement of an identical or nearly identical item that is still under 
waranty. This means that replacement of this equipment is not covered at this time. Therefore, we decided that 
the Plan does not have to pre-approve the flex walk system (L5981), multi-axial rotation unit (L5986), shock 
reducing pylon feature (L5988), axial rotation unit adjustment (L5984), and disartic alignable system (L5920).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 29, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim.  

The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on May 3, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the physician service. You say that you do not feel you should be responsible for 
this bill. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 Plan did not pre-approve the 
item/service at issue. 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 office visit (99213) provided on May 3, 2023, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87532, 87486, 87496, 87498, 87634, 
87581, and 87541 billed for date of service July 26, 2023. 
 
You asked the Plan to pay for the billed services. You say that the documentation justifies the services 
performed. The Plan denied your request. The Plan says the services cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
The file shows that a respiratory pathogen panel test was provided. In this case, we have confirmed that code 
87532, 87486, 87496, 87498, 87634, 87581, and 87541 is a column II code to column I code 87801. These 
codes have not been billed with an appropriate modifier to bypass the edit. We have also confirmed that code 
87150 is a column II code to column I code 87502. Code 87150 was billed with the XU modifier. The records 
do not show that this code was an unusual non-overlapping service. 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 
87150, 87532, 87486, 87496, 87498, 87634, 87581, and 87541 billed for date of service July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intraosseous radiofrequency ablation of the 
basivertebral nerve. 
 
You asked the Plan to pre-approve the intraosseous radiofrequency ablation of the basivertebral nerve. You say 
that the enrollee has tried and failed conservative treatments without relief. The Plan denied your request. The 
Plan says the intraosseous radiofrequency ablation of the basivertebral nerve is considered investigational. 
 
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 intraosseous radiofrequency 
ablation of the basivertebral nerve. Our reviewer says that the intraosseous radiofrequency ablation of the 
basivertebral nerve is considered investigational. Our physician reviewer found that the intraosseous 
radiofrequency ablation of the basivertebral nerve is considered an experimental and investigational procedure. 
Therefore, the request is not medically 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 the intraosseous radiofrequency ablation of the basivertebral nerve have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the intraosseous radiofrequency 
ablation of the basivertebral nerve.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 30, 2022, to 
May 4, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was accurately billed with the appropriate DRG. The Plan denied your request. The Plan says that the 
medical records did not have sufficient documentation to clinically validate the diagnosis of E87.1, (hypo-
osmolality and hyponatremia). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with E87.1. 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 pay for the inpatient hospital services at the DRG originally billed. Our physician 
reviewer found that the medical records did not demonstrate laboratory or clinical evidence of 
hyponatremia/hypo-osmolality requiring evaluation and treatment. The review has determined that the 
documentation did not support diagnosis code E87.1.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on April 30, 2022, to May 4, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) scan. 
 
You asked the Plan to pre-approve a cone beam CT scan. You say that the services should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as 
they do not fall within the enrollees dental 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 
cone beam computed tomography (CT) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 2, 2023, to May 10, 2023. 
 
You asked the Plan to pay for dental services. You say that this was medically necessary. The Plan denied your 
request. The Plan says these are not covered services. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
 The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services provided on May 
2, 2023, to May 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia in conjunction with operative or surgical 
procedures (D9215) provided on April 7, 2023. 
 
You asked the Plan to pay for D9215. You say that you need this dental work. The Plan denied your request. 
The Plan says the denied dental service is not a covered benefit. 
 
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 local 
anesthesia in conjunction with operative or surgical procedures (D9215) provided on April 7, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment without transport services 
received on July 26, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
you wanted to go to a hospital that you were more familiar with, so you had your spouse drive you there. The 
Plan denied your request. The Plan says without transport there are no payable services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 26, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment without 
transport services received on July 26, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for non-emergent ambulance transportation provided on July 21, 2023. 
 
You asked the Plan to pay for the non-emergent ambulance transportation. You say that the services were 
medically necessary to transport the enrollee due to their medical condition. The Plan denied your request. The 
Plan says that there was no prior authorization requested. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 pay for the non-emergent ambulance transportation. 
Our reviewer says that the non-emergency ambulance transportation was medically necessary. Our physician 
reviewer found the enrollee required cardiac monitoring. Other modes of transportation were contraindicated. 
Use of an ambulance was medically 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 the non-emergent ambulance transportation have not been met. Therefore, we 
decided that the Plan has to pay for non-emergent ambulance transportation provided on July 21, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 38510 and 38900 billed for date of service 
July 12, 2023.  
 
You asked the Plan to pay for the billed services. You say that the records support medical necessity. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 38510 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Because the primary procedure code 38510 is not payable in this case, the add-on 
code 38900, is also not payable. 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 procedure codes 
38510 and 38900 billed for date of service July 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair provided on December 12, 2022. 
 
You asked the Plan to pay for the wheelchair. You say that the wheelchair was your only option for mobility. 
The Plan denied your request. The Plan says the wheelchair must be rented and cannot be bought outright. The Plan follows Medicare rules. The rules say for capped rental items, contractors pay the fee schedule 
amounts on a monthly rental basis not to exceed a period of continuous use of 15 months. 
 
We looked at the file and the rules. The wheelchair you received is considered a capped rental item. This means 
that the option to purchase is only occurs only after 13 months of rental. Based on this information, we decided 
that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to 
pay for the wheelchair provided on December 12, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Herzuma in combination with Perjeta, docetaxel, and 
Udenyca. 
 You asked the Plan to pre-approve Herzuma in combination with Perjeta, docetaxel, and Udenyca. You say that 
the requested injection is medically necessary for the enrollee. The Plan denied your request. The Plan says the 
enrollee did not meet the step therapy requirements. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Herzuma in combination with Perjeta, 
docetaxel, and Udenyca. Our physician reviewer found that based on the medical records provided there is no 
indication that the enrollee has tried and failed the required drugs. According to the medical records provided 
and the Medicare-approved major drug compendia there is no indication that the plan's required drugs would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Herzuma in combination with Perjeta, docetaxel, and Udenyca have not been 
met. Therefore, we decided that the Plan does not have to pre-approve Herzuma in combination with Perjeta, 
docetaxel, and Udenyca.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87491 and 87640 
for July 6, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order for code 87491 and code 87640 is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider for code 87491. Without a record showing that this 
provider is treating the enrollee, the criteria for coverage of this testing have not been met.  
 
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 87640 
is a column II code to column I code 87641. The -59 modifier is not supported as a separate and distinct 
procedural service. Based on the claim submitted, Medicare billing criteria have not been met. 
 
Therefore, we decided that the Plan does not have to pay for the laboratory services billed with codes 87491 
and 87640 for July 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that the enrollee cannot go home without 
this equipment because it is a life-or-death situation. The Plan denied your request. The Plan says a home 
ventilator is not medically necessary for this patient because their needs can be met with an alternative device 
such as a BiPAP device with average volume-assured pressure support (AVAPS).   
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that there is no 
documented failure of AVAPS and no indication for a home ventilator. While the enrollee did fail standard 
BiPAP which was noted on the arterial blood gas test, they had improved when the AVAPS was administered. 
Therefore, a trial of a BiPAP with AVAPS is warranted as the enrollee tolerated and had improved acidosis. 
 
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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair ramp (E1399). 
 
You asked the Plan to pre-approve the wheelchair ramp. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this is a non-covered item. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve the wheelchair ramp (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unspecified maxillofacial prosthesis and unspecified 
fixed prosthodontic procedure (D5999, D6999). 
 
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 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 an 
unspecified maxillofacial prosthesis and unspecified fixed prosthodontic procedure (D5999, D6999).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says these services are not medically necessary for the enrollee. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you are receiving appropriate care in current acute care setting as provided by Health 
Plan. Documentation does not support that LTACH services are medically appropriate at this time. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.