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

 
We decided that the Plan does not have to pay for procedure code 00560 billed for date of service May 30, 
2023. 
 You asked the Plan to pay for procedure code 00560. You say that 00560 should be paid as billed because it is 
supported in the record and the enrollee returned to the operating room for complications. The Plan denied your 
request. The Plan says payment for code 00560 is bundled into payment for code 00567. 
 
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 00560 
is a column II code to column I code 00567. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 code 00560 billed for date of service May 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 15, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this service 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 laboratory services 
provided on May 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adult prophylaxis (D1110) and diagnostic procedure, by 
report (D0999) provided on July 21, 2023. 
 
You asked the Plan to pay for diagnostic procedure, by report. 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 adult 
prophylaxis (D1110) and diagnostic procedure, by report (D0999) provided on July 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV) (K0800). 
 
You asked the Plan to pre-approve a scooter. You say that you feel a power operated scooter will help preserve 
your independence and keep you safe. The Plan denied your request. The Plan says the POV is being denied 
because your medical needs can be met by using a rollator and transport chair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 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 scooter. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found you are modified independent for self-care in 
your apartment. Per NCD 280.3, the scooter is not medically necessary to complete self-care activities in your 
home. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power operated vehicle (POV) (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller 
harness (E2313), and expandable controller (E2377). 
 
You asked the Plan to pre-approve the items. You say that when three or more power seating 
functions/actuators/motors are provided, one unit of E2311, one unit of E2377, and one unit of E2313 are 
allowed. The Plan denied your request. The Plan says the electronic connection, expandable controller harness, 
and expandable controller cannot be covered as they are not medically necessary to control the three approved 
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 the items. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the mobility limitation cannot be sufficiently and safely resolved by the use of a fitted cane or 
walker or the enrollee does not have sufficient upper extremity function to self-propel an optimally-configured 
manual wheelchair. Additionally, if any power operated vehicle (POV) or power wheelchair (PWC) is only for 
use outside the home, it is denied as noncovered. The enrollee must also have the mental and physical 
capabilities to safely operate the power wheelchair and the home provides adequate access between rooms, 
maneuvering space, and surfaces for the operation of the PWC. 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. 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 the items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an electronic connection (E2311), expandable controller harness (E2313), and expandable 
controller (E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 heavy-duty power wheelchair with multiple 
power options (K0862) with related features and accessories. 
 
You asked the Plan to pre-approve a Group 3 heavy-duty power wheelchair with related features and 
accessories. You say that the request is a medical necessity for the enrollee. The Plan denied your request. The 
Plan says the requested items are not medically necessary. 
 
The Plan follows Medicare rules. The rules say that a Group 3 PWC is covered if the criteria listed in the 
Medicare rules section of this letter 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 a Group 3 heavy-duty power 
wheelchair with related features and accessories. Our reviewer says that the requested items are not medically 
reasonable and necessary in this case. Our physician reviewer found that the enrollee requires a power 
wheelchair for mobility and accomplishing daily activities. However, the clinical documentation is insufficient 
why a lower-level power wheelchair would not meet the enrollee's needs versus a Group 3 power wheelchair. 
There is inadequate clinical documentation regarding why the enrollee requires power tilt and recline and 
cannot adequately perform pressure relief. The clinical documentation indicates that the patient has 5/5 motor 
strength in the upper extremities and there is no history of skin breakdown. 
 
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 Group 3 heavy-duty power wheelchair with related features and accessories 
have not been met.  
  Therefore, we decided that the Plan does not have to pre-approve a Group 3 heavy-duty power wheelchair with 
multiple power options (K0862) with related features and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises and the mechanical traction therapy 
provided by a chiropractor on January 25, 2023. 
 
You asked the Plan to pay for the therapeutic exercises and the mechanical traction therapy. You say that the 
claim should be reprocessed for payment. The Plan denied your request. The Plan says the only covered 
chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the therapeutic exercises and the mechanical traction therapy provided by a 
chiropractor on January 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises and the office visit provided by a 
chiropractor on July 27, 2022, to, August 20, 2022. 
 
You asked the Plan to pay for the therapeutic exercises and the office visit. You say that you were told that the 
chiropractic visits were covered with a $20 copay. The Plan denied your request. The Plan says that an office 
visit and therapeutic exercises are not a covered benefit when billed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.   
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the therapeutic exercises and the office visit provided by a chiropractor on 
July 27, 2022, to, August 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous bilateral sacroiliac (SI) joint fusion 
(27279). 
 
You asked the Plan to pre-approve a percutaneous bilateral SI joint fusion. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has 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 a percutaneous bilateral SI joint fusion. 
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 compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested percutaneous bilateral sacroiliac joint fusion is 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 a percutaneous bilateral SI joint fusion have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a percutaneous bilateral sacroiliac (SI) joint fusion (27279).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve portable oxygen concentrator. You say that without portable oxygen you 
cannot go anywhere. The Plan denied your request. The Plan says the record does not show that portable 
oxygen tanks are not meeting your needs. 
 
The Plan follows Medicare rules. Medicare rules state that a portable oxygen concentrator may be covered if 
certain 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 portable oxygen concentrator. Our 
reviewer says that you do not meet criteria for this portable oxygen concentrator. Our physician reviewer found 
the record does not document that portable oxygen tanks do not meet your needs for mobility within the home. 
In addition, there is no documentation that SpO2 can be maintained greater than 91% during activity while 
using an oxygen conserving device at a flow rate of 1 to 4 L/min. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of portable oxygen concentrator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service June 21, 
2023. 
 You asked the Plan to pay for procedure code 81345. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 code 81345 billed for date of service June 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on June 9, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says per Local Coverage 
Article A58720, this type of testing must be billed with a single unit of service of a single code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on June 9, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imbruvica. 
 
You asked the Plan to pre-approve the medication. 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. While some oral anti-cancer drugs may be covered by Medicare Part B, Imbruvica does 
not fall within this coverage because it is intended by the manufacturer to be self-administered and is not 
identical to a non-self-administered anti-cancer drug. Therefore, we decided that the Plan does not have to pre-
approve Imbruvica.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested device is not medically necessary. 
 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 ventilator. Our reviewer says that the 
documentation does not support that the requested device is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of chronic respiratory failure consequent to chronic obstructive 
pulmonary disease. The provided records document that the home ventilator is being requested for use in an 
intelligent volume assured pressure support (IVAPS) mode which is a modality that could be provided by a 
bilevel positive airway pressure (BiPAP) device with average volume assured pressure support (AVAPS) and a 
back-up rate. Provided records do not document trial and failure of a BiPAP device with AVAPS and a back-up 
rate. The documentation does not provide adequate detailed information to meet Medicare criteria for coverage 
of a ventilator as opposed to a BiPAP device with AVAPS and a back-up rate. Therefore, the enrollee does not 
meet criteria for the requested device. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Sprint peripheral nerve stimulator (PNS) (64555). 
 
You asked the Plan to pre-approve the Sprint PNS. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. 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 Sprint PNS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Sprint PNS system is experimental for chronic pain treatment. 
 
   
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 Sprint PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Sprint peripheral nerve stimulator (PNS) (64555).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
August 8, 2023, to August 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that your dentist is no longer 
in-network. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an out-of-network provider on August 8, 2023, to August 15, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa injections. 
 You asked the Plan to pre-approve injections. You say that the preferred drug EUFLEXXA is medically 
necessary. The Plan denied your request. The Plan says the step therapy device Orthovisc or Supartz FX is 
preferred. 
 
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 injections. Our reviewer says that the 
requirements for coverage of Euflezza have not been met. Our physician reviewer found the Plan requires a 
trial of Orthovisc or Supartz FX before they will approve the requested drug. Based on the medical records 
provided, there is no indication the enrollee has tried and failed the required drugs. There is no indication that 
the Plans required drugs would likely be less effective 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 injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Empower hereditary cancer test (81432) provided on July 
12, 2023. 
 
You asked the Plan to pay for the Empower hereditary cancer test. You say that this test is medically necessary. 
The Plan denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that to be covered, the test has satisfactorily 
completed a TA by MolDX for the stated indications of the test. 
 
We looked at the file and Medicare rules. In this case the requested test has not completed a TA by MolDX. 
Based on this information, we decided that Medicare rules for coverage of the Empower hereditary cancer test 
have not been met. Therefore, we decided that the Plan does not have to pay for the Empower hereditary cancer 
test (81432) provided on July 12, 2023.