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

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and one power seating system motor (E2310). 
 
You asked the Plan to pre-approve an electronic connection between wheelchair controller and one power 
seating system motor. You say that you are currently wheelchair bound and cannot get around without the 
durable medical equipment necessities. The Plan denied your request. The Plan says although a single power 
feature is requested for this wheelchair, there is not a medical need to control this power option 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 between 
wheelchair controller and one power seating system motor. Our reviewer says that the requested items/services 
are not considered medically reasonable and necessary in this case. Our physician reviewer found you had a 
stroke and have impaired mobility. You have 4 out of 5 strength in your left upper extremity and 5 out of 5 
strength in your left lower extremity. Our reviewer also found that you have sufficient strength and function in 
upper extremities to manage standard power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection between wheelchair controller and one power seating 
system motor have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
electronic connection between wheelchair controller and one power seating system motor (E2310).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ViviGen allograft (20930). 
 
You asked the Plan to pre-approve a ViviGen allograft. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the ViviGen allograft in the setting of 
anterior cervical spine fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 ViviGen allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows 
this request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to 
corroborate that the requested allograft would be as safe or better than standard autograft procedures. There is 
no compelling rationale presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 ViviGen allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a ViviGen allograft (20930).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Medtronic Infuse BMP-2 allograft (20930). 
 
You asked the Plan to pre-approve a Medtronic Infuse BMP-2 allograft. You say that this is medically 
necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of the Medtronic 
Infuse BMP-2 allograft in the setting of posterior spinal fusion surgery has not been demonstrated in the peer-
reviewed literature. 
 
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 Medtronic Infuse BMP-2 allograft. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found BMP is not Food & Drug Administration (FDA) approved for use in 
the posterior lumbar spine. 
 
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 Medtronic Infuse BMP-2 allograft have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Medtronic Infuse BMP-2 allograft (20930).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (81226, 81227, 81240, 81241 and 81328) provided 
on January 12, 2023. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says that these codes are missing the necessary 
Dex-Z code on the claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the services at issue were actually rendered/performed in a state 
which is not under the jurisdiction of the Local Coverage Determination cited by the Plan. The state in question 
does not participate in the Molecular Diagnostics (MolDX) contractor program, and therefore MolDX rules do 
not apply. This means that the requirement of a Dex-Z code does not apply in this case, and the Plan has not 
substantiated their denial. Therefore, we decided that the Plan has to pay for laboratory services (81226, 81227, 
81240, 81241 and 81328) provided on January 12, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a coronectomy intentional partial tooth removal of impacted 
teeth (D7251) provided on March 1, 2023.  

You asked the Plan to pay for a coronectomy intentional partial tooth removal, impacted teeth (D7251). You 
say that when the provider attempted to remove the tooth you started to hemorrhage. You also say they used 
this procedure to seal off the blood vessels. The Plan denied your request. The Plan says is not covered under 
your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
coronectomy intentional partial tooth removal of impacted teeth (D7251) provided on March 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve absorbable nasal implants (30117, 30801, 30469). 
 
You asked the Plan to pre-approve absorbable nasal implants. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The 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 absorbable nasal implants. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found provided medical records and review of the current peer-reviewed medical literature do not document that use of absorbable nasal implants has been shown in controlled studies in a 
CMS-approved journal to result in long term health benefits in patients with hypertrophy of nasal turbinates.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of absorbable nasal implants have not been met. Therefore, we decided that the 
Plan does not have to pre-approve absorbable nasal implants (30117, 30801, 30469).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an expandable controller (E2377), harness (E2313), electronic 
connection between wheelchair controller and 2 or more power seating system motors (E2311), custom 
fabricated wheelchair back cushion (E2716), and toggle switch (K0108). 
 
You asked the Plan to pre-approve an expandable controller, harness, electronic connection, custom fabricated 
wheelchair back cushion, and toggle switch. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 an expandable controller, harness, 
electronic connection, custom fabricated wheelchair back cushion, and toggle switch. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the complexity of her seating and positioning needs necessitates a more complex group 3 power 
wheelchair base. The expandable controller with harness and electronic connection are necessary to operate the 
group 3 power wheelchair base and the three power options via a joystick. These components as well as the 
toggle switch are required to operate 3 or more power options on a group 3 power wheelchair. Given the 
enrollees complex seating needs and inability to perform pressure relief, she requires a wheelchair back 
cushion for positioning and pressure offloading when in the reclined position. Therefore, the expandable 
controller (E2377) with harness (E2313) and electronic connection (E2311) is medically necessary as well as 
the wheelchair back cushion and toggle switch. 
 
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 expandable controller, harness, electronic connection, custom fabricated wheelchair back cushion, and toggle switch have been met. Therefore, we decided that the Plan has to pre-
approve an expandable controller (E2377), harness (E2313), electronic connection between wheelchair 
controller and 2 or more power seating system motors (E2311), custom fabricated wheelchair back cushion 
(E2716), and toggle switch (K0108).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital care provided on February 15, 17, 18, and 19, 
2023. 
 
You asked the Plan to pay for the hospital care. 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 the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the hospital care have been met. There 
were no medical records provided for the February 15, 17, 18, and 19, 2023, dates of service for review. 
Therefore, we decided that the Plan does not have to pay for the hospital care provided on February 15, 17, 18, 
and 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oxygen concentrator provided on April 17, 2023. 
 
You asked the Plan to pay for the oxygen concentrator. You say that you are appealing the denial of the 
reimbursement for procedure code E1390. The Plan denied your request. The Plan says the item you purchased 
is not covered when purchased from a non-Medicare provider. 
 
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary].  
 
We looked at the file and Medicare rules. The provider is not enrolled in Medicare so this is not eligible for 
payment. Based on this information, we decided that Medicare rules for coverage of the oxygen concentrator 
have not been met. Therefore, we decided that the Plan does not have to pay for an oxygen concentrator 
provided on April 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87798, 87481, 87150, and 87500) provided 
on August 26, 2022. 
 
You asked the Plan to pay for the panel testing. 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 covered as billed.  

The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the panel testing have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the panel testing (87798, 87481, 87150, and 87500) provided on August 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 13, 2023, billed with 
code 81433. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 13, 2023, billed with code 81433.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe 
gingival inflammation (D4346) provided on July 11, 2023. 
 
You asked the Plan to pay for the dental service. You say that the dental service should be covered and without 
the dental services completed you would get an infection. The Plan denied your request. The Plan says the 
denial of payment for this service is correct, because the scaling in presence of generalized moderate or severe 
gingival inflammation is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on July 11, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the color kit, and hub cap color. 
 
You asked the Plan to pre-approve the color kit and hub cap color. You say that this is medically necessary for 
the enrollee. The Plan denied your request. The Plan says these items are not primarily medical in nature and 
therefore are 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 items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 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 the color kit, and hub cap color.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services. 
 
You asked the Plan to pre-approve acupuncture services. You say that you were in a car accident and have been 
told to see an acupuncturist. You say that you were told that the services would be covered. The Plan denied 
your request. The Plan says acupuncture is only covered for chronic low back pain. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.   
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, pain not associated to the back is not covered under 
your Medicare benefit. Therefore, we decided that the Plan does not have to pre-approve acupuncture services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 25, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is non-covered. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 25, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for PET scan provided on June 05, 2023. 
 
You asked the Plan to waive the coinsurance for PET scan. You say that you were under the impression that the 
PET scan was $95 or less. 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 35% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 35% coinsurance for PET scan. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies 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. The total you owe is $459.09 ($1,414.54 allowed amount x 35% = $495.09). Therefore, we decided that the Plan does not have to waive the coinsurance for PET scan provided on 
June 05, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on January 5, 
2023. 
 
You asked the Plan to pay for 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 pay for 
periodontal maintenance (D4910) provided on January 5, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on March 28, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that you were 
not informed the copayment would be so high. 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 $195 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $195 copayment for a magnetic resonance imaging (MRI). This item/service 
falls within the outpatient diagnostic tests 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 a magnetic resonance imaging (MRI) provided on March 28, 2023.