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

 
We decided that the Plan does not have to pay for immunization services provided on June 6, 2023. 
 
You asked the Plan to pay for immunization services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the requested services are not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide immunization 
services. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to immunization 
services. Therefore, we decided that the Plan does not have to pay for immunization services provided on June 
6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (scooter) 
(K0800). 
 
You asked the Plan to pre-approve a scooter. You say that the patient has Chronic Obstructive Pulmonary 
Disease (COPD) and is oxygen dependent so they cannot use a manual wheelchair. You also say that the 
patient's home does have enough space for the power operated vehicle, and it is medically necessary. The Plan 
denied your request. The Plan says the K0800 power operated vehicle (scooter) requested does not meet the 
requirements for approval. 
 
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 
criteria for coverage have not been met. Our physician reviewer found the documentation reveals the patient 
has a mobility deficit but does not reveal that this significantly impairs MRADLs in the home. The 
documentation does not clearly reveal that the patient's caregiver cannot use a manual wheelchair. Our 
reviewer also found that there is no evidence that there is enough room in the patient's home for the scooter to 
safely maneuver. 
 
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 group 1 standard power operated vehicle (scooter) (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre 3 continuous glucose monitor 
(CGM) system. 
 
You asked the Plan to pre-approve the CGM. You say that the enrollee is appealing with medical records. The 
Plan denied your request. The Plan says  the enrollee is not on insulin and there are no documented 
hypoglycemia episodes. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 CGM. Our physician reviewer 
found the coverage criteria for CGM require low blood glucose sugar (BGS) or insulin use. You are not using 
meds that can cause low BGS and are not having low BGS that our physician reviewer is told of. Therefore, 
although the CGM may help you, the coverage criteria are not met. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the FreeStyle Libre 3 continuous glucose monitor (CGM) system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 82785 billed for date of service August 15, 
2023. 
 
You asked the Plan to pay for procedure code 82785. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says this claim was not submitted with a 
diagnosis which supports the medical necessity of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes which support 
the medical necessity of code 82785. Any codes which are not listed are considered not medically necessary for 
code 82785. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 82785 have not been met. Specifically, this claim was submitted with a diagnosis 
code which is not among those codes listed as medically necessary and appropriate for this service. Therefore, we decided that the Plan does not have to pay for procedure code 82785 billed for date of service August 15, 
2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedures provided on November 15, 2022. 
 
You asked the Plan to pay for procedures. You say that you are requesting reconsideration for the denied claim. 
The Plan denied your request. The Plan says that you did not send them the request within 60 days of their 
denial. 
 
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. We find that the medical records have been provided to support the services at 
issue and the Plan has provided no new reason for denial. Therefore, we decided that the Plan has to pay for 
procedures provided on November 15, 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital care provided on August 8, 2023, to August 16, 
2023. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the service was billed correctly and 
should be paid. The Plan denied your request. The Plan says that enrollee was admitted a second time for the 
same reason as prior admission. The enrollee was discharged prematurely, and the second admission could 
have been avoided. 
 
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
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 pay for the inpatient hospital care. Our physician 
reviewer found upon discharge from the prior admission, which was 10 days prior, the patient reported feeling 
better, without vomiting, pain improved, and showed stable labs. Although the readmission was medically 
necessary due to recurrence of abdominal pain, the readmission did not necessarily result from a premature 
discharge from the same hospital as the patient was stable and appropriate for discharge on July 29, 2023.  
 
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 inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the inpatient hospital care provided on August 8, 2023, to August 16, 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 the re-evaluation  post-operative office visit (D0171) 
provided on August 9, 2023. 
 
You asked the Plan to pay for the re-evaluation  post-operative office visit. You say that you have submitted a 
copy of your dental history. You also say that your upper denture had holes in two of the teeth and the lower 
denture was very loose, flat and hard for you to chew. The Plan denied your request. The Plan says this 
procedure is not covered under your dental plan. 
 
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the re-evaluation 
 post-operative office visit (D0171) provided on August 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital inpatient or observation discharge day 
management billed with code 99238 and subsequent hospital inpatient or observation services billed with code 
99232 provided on August 8, 2023, to August 10, 2023. 
 You asked the Plan to pay for the hospital inpatient or observation discharge day management and subsequent 
hospital inpatient or observation services. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that E11.00 has an Excludes1 note in relation to R73.09. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the hospital inpatient or observation discharge day management and subsequent hospital 
inpatient or observation services have not been met. Therefore, we decided that the Plan does not have to pay 
for the hospital inpatient or observation discharge day management billed with code 99238 and subsequent 
hospital inpatient or observation services billed with code 99232 provided on August 8, 2023, to August 10, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 for date of service July 20, 2023. 
 
You asked the Plan to pay for procedure code 99222. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that E83.52 (Hypercalcemia) has an Excludes1 note in relation to N20.0 
(Calculus of kidney). This means that the two diagnosis codes cannot be reported together. Based on this 
information, we decided that the Medicare billing rules for procedure code 99222 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99222 for date of service July 20, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller harness (E2313), expandable 
controller (E2377), and red corvette accent color (K0108). 
 
You asked the Plan to pre-approve an expandable controller harness, expandable controller, and red corvette 
accent color. The Plan denied your request. The Plan says given no power options are requested, the requested 
expandable controller harness and expandable controller cannot be approved. The Plan also says that the 
requested accent color does not serve a medical purpose, and cannot be covered as it is not reasonable and 
necessary per Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules also say that for equipment to be covered, it must primarily serve a 
medical purpose. 
 
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, 
expandable controller, and red corvette accent color. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the provided medical 
records from the physician do not document the need for an expandable controller (E2377) to operate an input 
device or to operate 3 or more powered seating actuators. The provided medical records from the physician do 
not document the necessity of a harness (E2313) for the operation of an expandable controller. Our reviewer 
also found that the requested accent color does not serve a medical purpose and does not meet Medicare criteria 
for medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. The red corvette accent color (K0108) does 
not serve a purpose that is primarily medical in nature. Based on this information, we decided that Medicare 
rules for coverage of an expandable controller harness, expandable controller, and red corvette accent color 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller 
harness (E2313), expandable controller (E2377), and red corvette accent color (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
March 31, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the test panel was not billed as a single unit of 
service. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) 
panel rendered on March 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two seat belts (E0978 x2), electronic connection 
(E2311), Sedopro aftermarket back adapter (K0108), cell phone holder (K0108), cup holder (K0108), power 
module R-net (K0108), and a headrest adapter (K0108).  

You asked the Plan to pre-approve two seat belts (E0978 x2), electronic connection (E2311), Sedopro 
aftermarket back adapter (K0108), cell phone holder (K0108), cup holder (K0108), power module R-net 
(K0108), and headrest adapter (K0108). You say that you would like the denial to be reviewed and overturned. 
The Plan denied your request. The Plan says mounting hardware is included with the back cushion and cannot 
be requested separately. The requested cell phone holder and cup holder do not serve medical purposes and 
cannot be covered as they are not reasonable and necessary per Medicare criteria. The Plan says the joystick 
controller display is part of the expandable controller and should not be requested separately. The headrest 
hardware is incorrectly coded and unbundled. The Plan also says that a seat belt is already included with the 
power wheelchair. 
 
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 two seat belts (E0978 x2), electronic 
connection (E2311), Sedopro aftermarket back adapter (K0108), cell phone holder (K0108), cup holder 
(K0108), power module R-net (K0108), and headrest adapter (K0108). Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested items are included with the wheelchair. Our reviewer also found that the cellphone holder 
and cup holder are not medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. The cell phone holder and cup holder 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. Based on this information, we decided that Medicare rules 
for coverage of two seat belts (E0978 x2), electronic connection (E2311), Sedopro aftermarket back adapter 
(K0108), cell phone holder (K0108), cup holder (K0108), power module R-net (K0108), and headrest adapter 
(K0108) have not been met. Therefore, we decided that the Plan does not have to pre-approve two seat belts 
(E0978 x2), electronic connection (E2311), Sedopro aftermarket back adapter (K0108), cell phone holder 
(K0108), cup holder (K0108), power module R-net (K0108), and a headrest adapter (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on September 16, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the home visit provided on September 16, 2023, 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted procedure of the nervous system (64999) 
provided on July 19, 2023. 
 
You asked the Plan to pay for the procedure. You say that the service was billed correctly and should be paid. 
The Plan denied your request. The Plan says there is a more appropriate procedure code that describes the 
services provided. Unlisted procedure code 64999 is 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 64999 is unlisted procedure, nervous system. 
 
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 the test. Our reviewer found the medical report does not include documentation of the procedure being reported with an unlisted procedure code and therefore cannot be 
verified. The documentation supports a peripheral nerve block and lumbar plexus was performed, which has an 
assigned CPT code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the test have not been met. Therefore, we decided that the Plan does not have to 
pay for the unlisted procedure of the nervous system (64999) provided on July 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve massage therapy. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the requested service is not considered reasonable 
and necessary, according to the standards of Original Medicare. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a knee arthroplasty, and the inpatient 
hospital stay provided from August 9, 2023, to August 15, 2023. 
 
You asked the Plan to waive the copayments for a knee arthroplasty, and the inpatient hospital stay. You say 
that you cannot afford the copayments. 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 $280 copayment for the in-network surgery services. Your contract with the Plan also clearly says that you must pay 
a $350 copayment per day, for days one to five and a $0 copayment after day five for in-network covered 
hospital care. 
 
You have been asked to pay a $280 copayment for a knee arthroplasty provided on August 9, 2023. This 
item/service falls within the outpatient surgery, including service provided at hospital outpatient facilities 
benefit category. You have also been asked to pay a $350 copayment per day, for days one to two of the 
inpatient hospital stay provided from August 10, 2023, to August 15, 2023. The total amount you owe for the 
inpatient hospital care is $700 ($350 copayment x 2 days = $350). This item/service falls within the inpatient 
hospital 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 copayments for a knee arthroplasty, and 
the inpatient hospital stay provided from August 9, 2023, to August 15, 2023.