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

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a group 1 standard power operated vehicle. You say that you have been 
trying to get a power operated vehicle since July of 2022, have done all the evaluations and physical therapy, 
but continue to have difficulty walking. You also say that you suffered a heart attack, and your condition does 
not allow you to be able to maneuver a manual wheelchair. The Plan denied your request. The Plan says the 
documentation indicates that you are able to complete MRADLs using your rollator walker in the home and in 
the community, are independent with your instrumental activities of daily living and activities of daily living 
and are ambulatory for household distances and limited community distances using your rollator walker. 
 
 
 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 group 1 standard power operated 
vehicle. Our reviewer says that you do not meet the criteria for coverage. Our physician reviewer found the 
record does not address safety or appropriateness of a power operated vehicle for 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 group 1 standard power operated vehicle have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (K0800).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 28, 2023, 
to March 29, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 28, 2023, to 
March 29, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee has an absence of non-vertebrogenic pathology which could 
explain the pain. The enrollee has disc disease, thecal sac impingement, facet arthropathy, and neuroforaminal 
stenosis. Modic changes extend beyond L3-S1. The enrollee has radicular pain, and this is the predominant 
pain source. The enrollee's body mass index is greater than 40. The enrollee has not had a multidisciplinary 
assessment to include a psychological evaluation. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found magnetic resonance imaging shows stenosis and facet degenerative joint disease. The 
cause of back pain is not clear.  
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for continuous glucose monitor supplies (K0553) billed for date of service 
December 8, 2022. 
 
You asked the Plan to pay for CGM supplies. You say that you have billed the items at issue correctly. The 
Plan denied your request. The Plan says that the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does contain a valid physician order and proof of delivery. Review of the file does not reveal any 
reason that the required documentation is invalid. Therefore, we decided that the Plan has to pay for continuous 
glucose monitor supplies (K0553) billed for date of service December 8, 2022.  
 
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 retainer crowns (D6740), a core build-up (D2950), and a 
pontic (D6245), provided on March 21, 2023. 
 
You asked the Plan to pay for D6740, D2950, and D6245. You say that bridges should be covered. The Plan 
denied your request. The Plan says the denied services are not covered 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 retainer 
crowns (D6740), a core build-up (D2950), and a pontic (D6245), provided on March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital inpatient or observation care provided on 
December 11, 2022. 
 
You asked the Plan to pay for initial hospital inpatient or observation care. The Plan denied your request. The 
Plan says the Plan's subrogation spoke with the member's wife (consent is on file with the Plan), and she 
confirmed this treatment should go to workers compensation for processing payment.  
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed 
that these services should be billed to workers compensation for processing. As the secondary insurer, the Plan 
cannot be held responsible for initial hospital inpatient or observation care until the primary insurer has denied 
the claim for these services. Therefore, we decided that the Plan does not have to pay for initial hospital 
inpatient or observation care provided on December 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 CDx (0242U) provided on May 13, 2021. 
 
You asked the Plan to pay for Guardant360 CDx. You say that this test was medically necessary and is 
supported in the medical records. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of Guardant360 CDx 
have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 CDx (0242U) 
provided on May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that no one is available within your Plan's medical group and you do not want to see the  in-network dermatologist. You say that this is urgent because you are bleeding. The Plan denied your request. 
The Plan says You must receive your care from a network provider. In most cases, care you receive from an 
out-of-network provider (a provider who is not part of our plans network) will not be covered. Exceptions are 
allowed when care cannot be provided by the primary care physician's medical group. The Plan say an in-
network dermatology provider is well qualified to take care of this member. 
 
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 contract with 
the Plan also says that the Plans PCPs are affiliated with particular medical groups. This means that your PCP 
will be referring you to specialists and services that are also affiliated with his or her medical group. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nebulizer supplies billed for date of service March 19, 2023. 
 
You asked the Plan to pay for the nebulizer supplies. You say that you have provided all required documents 
and expect payment on this claim. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
 The record does not contain a valid proof of delivery for the supplies provided in this case. There is no 
documentation of the method of delivery or the date of delivery of this item. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for nebulizer supplies billed for date of service March 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for office visits on February 15, 2022, to February 13, 2023.

You asked the Plan to waive the copayments for office visits. You say that you want to appeal the amount being charged. 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 $50 copayment for each Medicare-covered podiatry visit. Covered services include diagnosis and the medical or surgical treatment of injuries and diseases of the feet (such as hammer toe or heel spurs) and routine foot care for members with certain medical conditions affecting the lower limbs. There were six visits. 6 x $50 = $300. Therefore, results in the total cost sharing amount of $300.

You have been asked to pay a $50 copayment for each office visit. This item/service falls within the podiatry services 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 copayments for office visits on February 15, 2022, to February 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92610 billed for date of service February 1, 
2023. 
 You asked the Plan to pay for procedure code 92610. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says payment for code 92610 is bundled into payment for 
codes 92612 and 92613. 
 
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 92610 is a column II code to column I codes 92612 and 92613; 
however, 92610 was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 92610. Our reviewer says that procedure 
code 92610 does not meet criteria for payment. Our reviewer found that you reported the procedure code and 
appended modifier 59 (distinct procedural service) to bypass the edit with codes 92612 and 92613. The 
procedure report documents a normal clinical swallow exam followed by a more comprehensive swallow 
exam. In this case, procedure code 92610 billed with modifier 59 cannot be verified as a distinct procedural 
service from the more comprehensive procedures billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 92610 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 92610 billed for date of service February 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve ablation (64624). 
 
You asked the Plan to pre-approve a genicular nerve ablation. 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 a genicular nerve ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered experimental therapy. It is the subject of ongoing clinical 
trials 
 
   
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 genicular nerve ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a genicular nerve ablation (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion interspinous spacer (Vertiflex). 
 
You asked the Plan to pre-approve Vertiflex. You say that the enrollee has had no success with conservative 
treatments and that this is medically necessary. The Plan denied your request. The Plan says that there is a lack 
of evidence to support interspinous spacer devices as safe and effective as the gold standard of surgical 
decompression. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that current evidence-based medical guidelines and peer-reviewed literature do not fully 
support the spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a 
lack of large volume, long-term, peer-reviewed outcome studies to support the use of this device for this 
enrollees medical condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vertiflex.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tracheostomy supplies billed for date of service March 7, 
2023. 
 
You asked the Plan to pay for tracheostomy supplies. You say that you have reported the items at issue 
correctly. The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for tracheostomy supplies billed for date of service March 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code E1399 that 
were issued on December 27, 2022. You asked the Plan to pay for the compression stockings. You say that medical records were provided. The 
Plan denied your request. The Plan says the service as billed is not covered. 
 
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 record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means 
that the enrollee does not have a medical condition for which compression garment can be covered or paid for 
by Medicare. Based on this information, we decided that the Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code 
E1399 that were issued on December 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for glasses and eye exam on September 01, 
2022.  
 
You asked the Plan to waive the cost share for glasses and eye exam. You say that you want to return the 
glasses because they are useless, and you can't see out of them. 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 $25 
copayment for each yearly routine eye exam. Covered services include One (1) routine eye exam per year. 
Allowance towards the purchase of a complete set of eyeglasses or contact lenses every two years. The 
provider billed in the amount of $268 and there is a $25 copayment. $268 + $25 = $293. Therefore, results in 
the total cost sharing amount of $293. 
 
You have been asked to pay a $293 cost share for glasses and eye exam. This item/service falls within the 
vision care 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 cost share for glasses and eye exam on 
September 01, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 28, 2022, to 
November 26, 2022. 
 You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is August 29, 2022. The NOA was not received by the Plan until January 27, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from October 28, 2022, to November 26, 2022.