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

 
We decided that the Plan does not have to pre-approve a power wheelchair with related accessories. You asked the Plan to pre-approve the requested wheelchair. You say that the enrollee has a debilitating 
neuromuscular disease. The Plan denied your request. The Plan says the requested wheelchair was incorrectly 
coded. 
 
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 standard wheelchair (code E1130), a dual mode battery charger (code E2367), and 
hydraulic lift (code E0630) were requested. The billed code, E1130, is not a valid code for a power wheelchair. 
Since the requested base code is not valid in this case, the related accessories are also not covered. 
Additionally, the requested charger is included in the allowance for a power wheelchair base and not separately 
payable. Based on this information, we decided that Medicare rules for coverage of the requested wheelchair 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair with 
related accessories.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 7, 2023. 
 You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance services provided on May 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99205) and brief emotional/behavioral 
assessment (96127) provided on June 26, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physician services. You say that your family doctor gave you a referral for 
you high anxiety. You say that you were told your referral was approved. You also say that you feel this should 
be covered. The Plan denied your request. The Plan says there is no referral from your primary care physician 
(PCP). 
 
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 in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these items/services. The record shows that 
a referral was made for the services at issue, however, the Plan requires that referrals are made by your primary 
care physician. The provider in this case is not listed as your primary care physician with the Plan. Therefore, 
we decided that the Plan does not have to pay for the office visit (99205) and brief emotional/behavioral 
assessment (96127) provided on June 26, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on October 11, 
2023. 
 
You asked the Plan to pay for chiropractic manipulative treatment. 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 chiropractic 
manipulative treatment provided on October 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97813 and 97814 provided from March 13, 
2023, to March 20, 2023.  

You asked the Plan to pay for procedure codes 97813 and 97814. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 97813 is Acupuncture, 1 or more needles; with electrical 
stimulation, initial 15 minutes of personal one-on-one contact with the patient. The definition of code 97814 is 
Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one 
contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary 
procedure). 
 
We find that CPT codes 97813 and 97814 are not supported in the medical record. Specifically, the code 
definition for each is time-based, and the records submitted for review do not document the total time spent 
providing the services described by these codes. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 97813 and 97814 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 97813 and 97814 provided from March 13, 2023, to March 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77066 and 77062 billed for date of service 
June 29, 2023.  
 
You asked the Plan to pay for procedure codes 77066 and 77062. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the number of units billed for 
procedure code 77066 exceeds the maximum allowed. Additionally, procedure code 77062 is invalid for 
Medicare purposes. 
 
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. Medicare rules also say that providers must 
report services correctly. Providers must report services with the appropriate procedure code. 
 
In this case, the MUE for CPT code 77066 is 1. The MAI value for this code is 2. You billed 3 units of this 
code, exceeding the MUE. Additionally, we find that procedure code 77062 has a Status Indicator of I on the 
Physician Fee Schedule. This means that procedure code 77062 is not valid for Medicare purposes. Based on 
this information, we decided that Medicare rules for coverage of procedure codes 77066 and 77062 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 77066 and 77062 billed 
for date of service June 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) for tooth #7 provided on May 22, 
2023. 
 
You asked the Plan to pay more for the dental service. You say that you are appealing the denial of the claim 
because the services were necessary to restore teeth to proper function. The Plan denied your request. The Plan 
says the enrollee's annual dental maximum benefit for the year 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 the Plan paid $2,000 for dental services on May 22, 2022; therefore, the enrollee's annual dental 
maximum benefit for the year of 2023 was exhausted on the date of service of May 22, 2023. Therefore, we 
decided that the Plan does not have to pay more for a crown (D2740) for tooth #7 provided on May 22, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on September 2, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
the services were medically necessary. 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 September 2, 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 the ambulance response and treatment without 
transport services received on September 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injection. 
 
You asked the Plan to pre-approve repeat epidural steroid injection. You say that this is medically necessary. 
The Plan denied your request. The Plan says this does not meet the LCD criteria for coverage. 
 
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 repeat epidural steroid injection. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there is no 
documentation provided indicating at least 50% of sustained improvement in pain relief and/or improvement in 
function measured from baseline using SAME scale for at least 3 months after the first intralaminar epidural 
steroid injection on 12/2022. The requested repeat injection does not appear to be via a different approach, 
location or with a different medication. The review has determined that the enrollee does not meet the LCD 
criteria for coverage. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat epidural steroid injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve repeat epidural steroid injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Self-Administered drugs on November 8, 2023. 
 
You asked the Plan to pay for the medication. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Self-Administered drugs on 
November 8, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care. provided on August 28, 2023, to 
September 06, 2023. 
 
You asked the Plan to pay for the nursing facility care.. You say that the services rendered 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the nursing facility care. 
provided on August 28, 2023, to September 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care. provided on September 06, 2023. 
 
You asked the Plan to pay for nursing facility care.. You say that you would like reconsideration based on the 
records submitted. 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 nursing facility care. 
provided on September 06, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone. 
 
You asked the Plan to pre-approve Oxycodone. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxycodone.  Benefits for Oxycodone may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Coflex device. 
 
You asked the Plan to pre-approve the Coflex device. You say that this is medically necessary. The Plan denied 
your request. The Plan says there are not enough studies on Coflex to show it is safe and effective. 
 
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 Coflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no spinal instability on flexion/extension films. There is no discussion of 
scoliosis of the lumbar spine and/or documentation of the Cobb angle. There is no discussion indicating that a 
bone scan has demonstrated the lack of significant osteoporosis in this patient. There is no compelling rationale 
presented, or extenuating circumstances noted to support the medical necessity of this request as an exception 
to guidelines. 
 
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 Coflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Coflex device.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the procedure code 87635 provided on August 4, 2023. 
 You asked the Plan to pay for the procedure code 87635. You say that the services were medically necessary. 
The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the procedure code 87635 provided on August 4, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 3, 2023. 
 You asked the Plan to pay for the office visit. You say that the services provided were not related to the 
enrollee's hospice diagnosis. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an office visit provided on October 3, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT). provided on September 22, 
2023. 
 
You asked the Plan to pay for computed tomography (CT).. You say that the CT scan was 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 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 computed tomography 
(CT). provided on September 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the medical eye exam (92004), eye 
refraction (92015), and fundus photography (92250) provided on August 15, 2023. 
 
You asked the Plan to waive the copayment for the eye exam, eye refraction, and fundus photography. You say 
that this visit should have been $0 because you had a retinopathy eye exam, and your visit was routine. 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 $35 
copayment for vision care.  
 You have been asked to pay a $35 copayment for the eye exam, eye refraction, and fundus photography. These 
services fall within the vision care benefit category. Specifically, the record shows that you were billed for a 
medical eye exam (92004), and not a routine exam. 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 medical eye exam (92004), eye refraction (92015), and fundus photography (92250) provided on August 
15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided on September 29, 2023, by an 
OON provider.  
 
You asked the Plan to pay for surgery. You say that this was medically necessary. The Plan denied your 
request. The Plan says services provided OON are 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 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 surgical services provided on September 29, 2023, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote monitoring of physiologic parameter(s) provided on 
June 16, 2023. 
 
You asked the Plan to pay for remote monitoring of physiologic parameter(s). You say that the 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 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 remote monitoring of 
physiologic parameter(s) provided on June 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service June 17, 
2023.  
 
You asked the Plan to pay for procedure code 99232. You say that 99232 should be paid as billed because it is 
supported in the medical record. 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 99232 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 99232 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99232 billed for date of service June 17, 2023.