Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telemedicine visit provided on April 27, 2022. 
 
You asked the Plan to pay for a telemedicine visit. You say that this is supported in the records. 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 telemedicine visit 
provided on April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided on May 3, 2023. 
 
You asked the Plan to pay for D2740. You say that crowns should be covered. The Plan denied your request. 
The Plan says the rendered 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 a crown 
(D2740) provided on May 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 (CGM) and diabetic supplies.  
You asked the Plan to pre-approve a CGM and diabetic supplies. You say that pricking your fingers has 
become very painful. The Plan denied your request. The Plan says the medical criteria for a CGM have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin. 
Based on this information, we decided that Medicare rules for coverage of a CGM and diabetic supplies have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 (CGM) and 
diabetic supplies.
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 19, 2023. 
 
You asked the Plan to pay for local anesthesia in conjunction with operative or surgical procedures. You say 
that this should be covered. The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for local 
anesthesia in conjunction with operative or surgical procedures (D9215) provided on April 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network cardiology visit provided on 
March 14, 2023. 
 
You asked the Plan to waive the copayment for an in-network cardiology visit. You say that this plan has made 
this whole process very confusing. You have had to fix many appointment mistakes and this is not acceptable. 
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 $45 
copayment for covered in-person or telehealth visit or consultation in an outpatient location with a specialist. 
 
You have been asked to pay a $45 copayment for an in-network cardiology visit. This item/service falls within the covered in-person or telehealth visit or consultation in an outpatient location with a specialist 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 an in-network cardiology visit provided on 
March 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orthopedic consultation to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve an orthopedic consultation. You say that you want to go to this provider 
because they specialize in your condition. The Plan denied your request. The Plan says there are other 
providers available who are in-network, who are within the Medicare allowable distance from your residence. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an orthopedic consultation to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that this dental work should be covered. The Plan 
denied your request. The Plan says your annual dental allowance amount 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 annual dental allowance amount was exhausted on date of service March 7, 2023, when the Plan 
paid $1,645. Therefore, we decided that the Plan does not have to pay for dental services provided on March 7, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (EKG) provided on February 25, 2022. 
 
You asked the Plan to pay for an electrocardiogram (EKG). You say that this was medically necessary and 
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 an electrocardiogram 
(EKG) provided on February 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair provided on January 21, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the wheelchair. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 
 
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 wheelchair provided on January 21, 2023, by 
an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93971 billed for date of service March 27, 
2023.  
 
You asked the Plan to pay for procedure code 93971. You say that you disagree with the denial. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 93971 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 93971 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 93971 billed for date of service March 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair of nasal valve collapse (30469) and excision of 
intranasal lesion, internal approach (30117 x 2). 
 
You asked the Plan to pre-approve the repair of nasal collapse and excision of lesion. You say that the 
requested services should be approved as they are coverable by Medicare. The Plan denied your request. The 
Plan says this procedure is unproven for treatment of nasal valves and other intranasal obstructions. 
 
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 repair of nasal collapse and excision 
of lesion. Our reviewer says that the requested repair of nasal collapse and excision of lesion are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the 
enrollee has nasal obstruction and chronic sinusitis. There is insufficient literature to support the safety and 
efficacy of the requested service for the enrollee's specific conditions. The record provided does not establish 
the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. Therefore, the 
reviewer found that the requested repair of nasal collapse and excision of lesion are 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 repair of nasal collapse and excision of lesion have not been met. Therefore, 
we decided that the Plan does not have to pre-approve repair of nasal valve collapse (30469) and excision of 
intranasal lesion, internal approach (30117 x 2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra link for link headrest hardware (K0108) and a 
power seat elevation system (E2300). 
 
You asked the Plan to pre-approve an extra link for link headrest hardware. The Plan denied your request. The 
Plan says the unilink hardware is incorrectly coded and cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that miscellaneous options, accessories, or 
replacement parts for wheelchairs that do not have a specific HCPCS code and are not included in another code 
should be coded K0108. 
 
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 extra link for link headrest hardware. 
Our reviewer says that the requested item does not meet the coverage criteria. Our physician reviewer found 
the headrest accessory has a HCPCS code and therefore K0108 is a miscode. 
 
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 extra link for link headrest hardware have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an extra link for link headrest hardware (K0108) and a 
power seat elevation system (E2300).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TheraSkin. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that skin substitutes are covered when specific 
criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a full thickness skin 
loss ulcer of the heel. A wound clinic note dated July 17, 2023 indicates that he is receiving treatment for 
bilateral pressure wounds on the heels. He was noted to inconsistently use an off-loading orthosis while in bed. 
The left heel is described as an unstageable pressure ulcer measuring 2.8 by 6.3 by 0.1 centimeters post-
debridement on July 17, 2023. On June 12, 2023 post-debridement measurements were 3.4 by 8.3 by 1 
centimeters. The records do not show that the heel wound is not responding to treatment. The wound 
measurements from June to July of 2023 demonstrate reduction in wound size. The criteria for coverage are not 
met and the TheraSkin is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve TheraSkin.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lesion removal provided on April 6, 2023, by an OON 
provider.  You asked the Plan to pay for the lesion removal. You say that the provider is in-network with the Plan. The 
Plan denied your request. The Plan says the provider is out-of-network, and the services were not authorized. 
 
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 contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 lesion removal provided on April 6, 2023, by 
an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87493 billed for date of service March 30, 
2023. 
 
You asked the Plan to pay for procedure code 87493. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment 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, the CPT Code Manual definition of code 87493 is: Infectious agent detection by nucleic acid 
(DNA or RNA); Clostridium difficile, toxin gene(s), amplified probe technique. 
 
We find that CPT code 87493 is not supported in the medical record. Specifically, the provided medical records 
did not include the results of the testing at issue. Based on this information, we decided that Medicare rules for 
coverage of procedure code 87493 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 87493 billed for date of service March 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
you would like the documentation to be reconsidered for the recommended components needed to meet the 
enrollee's current medical, mobility & functional needs. The Plan denied your request. The Plan says although 
there are three requested power options (tilt, recline and elevating leg rests), 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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found an expandable controller is an electronic 
system that is capable of accommodating one or more additional features and can operate 3 or more powered 
seating options. The requested electrical accessories are not medically necessary as the enrollee does have use 
of the upper extremity and can operate and control the power options using the switches that are included in the 
basic wheelchair. Our reviewer also found that there is not a medical need for the upgraded electronics. 
 
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, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the clinical documentation does not show that your 
condition and treatment plan require an inpatient level of care. The Plan states the clinical documentation 
indicates that you do not have a significant neurological impairment or conditions such as a change in mental 
status, new or worsening neurologic condition, altered level of consciousness, significant change in motor 
speech or sensory. The Plan states the submitted clinical documentation does not show that you require neurological assessment at least three times in 24 hours. The Plan states you have been approved for the 
treatment of migraine headaches in an ambulatory (outpatient) setting.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the review has determined the clinical documentation did not show that 
your condition and treatment plan required an inpatient level of care. Additionally, the clinical documentation 
indicated that you did not have a significant neurological impairment or conditions such as a change in mental 
status, new or worsening neurologic condition, altered level of consciousness, significant change in motor 
speech or sensory. The review has determined that the items/services at issue in this case were 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that you are appealing the denial of 
the seat elevator as this is medically necessary because you cannot stand on your own.  The Plan denied your 
request. The Plan says a power seat elevation feature is not needed for your health and is not covered. 
 
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 power seat elevation system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found in this case, the requested power seat elevation system does not serve a 
primarily medical purpose therefore 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 a power seat elevation system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power seat elevation system (E2300).