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

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. The Plan denied your request. The Plan says this 
item is not covered.  
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wrist hand finger orthosis (L3809) to be provided by 
an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the wrist hand finger orthosis. You say that the item should be covered. The 
Plan denied your request. The Plan says this item is available in-network. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the wrist hand finger orthosis (L3809) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve carboplatin, vincristine sulfate, and atezolizumab. 
 
You asked the Plan to pre-approve the drugs. You say that the enrollee has been on this therapy and has had 
positive results.  The Plan denied your request. The Plan says the requested drugs are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drugs. Our reviewer says that the 
requested drugs are not medically necessary. Our physician reviewer found that the requested use of 
carboplatin, vincristine sulfate, and atezolizumab are not FDA- approved. The requested drugs are also not 
supported by one of the major drug compendia or by clinical research. 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 drugs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve carboplatin, vincristine sulfate, and atezolizumab.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 16 trips for routine transportation. 
 
You asked the Plan to pre-approve the additional routine transportation. You say that the transportation is 
needed to attend medical appointments and physical therapy. The Plan denied your request. The Plan says you 
have exceeded your limits set in the subscriber agreement for additional routine transportation. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 16 trips for routine transportation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
June 6, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service June 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unspecified periodontal procedure (D4999) provided on July 
26, 2022. 
 
You asked the Plan to pay for D4999. You say that you believe that this should be covered and paid by the 
Plan. The Plan denied your request. The Plan says the denied dental service is not a covered benefit. 
 
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 
unspecified periodontal procedure (D4999) provided on July 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and chiropractic manipulative treatment 
provided by a chiropractor on May 8, 2023. 
 
You asked the Plan to pay for the office visit. You say that you have back pain, and the chiropractor helps 
relieve the pain and helps you not having to take medications. The Plan denied your request. The Plan says that 
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 office visit and chiropractic manipulative treatment provided by a 
chiropractor on May 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F3 Color Kit - Mossy Oak Break-Up (K0108). 
 
You asked the Plan to pre-approve F3 Color Kit - Mossy Oak Break-Up. You say that the items are necessary. 
The Plan denied your request. The Plan says the requested items are not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.    

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
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 F3 Color Kit - Mossy Oak Break-Up (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944) provided on January 16, 2023. 
 
You asked the Plan to pay for D9944. You say that you were advised you were in-network. The Plan denied 
your request. The Plan says the denied dental service is not a covered benefit.  

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 an 
occlusal guard (D9944) provided on January 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 provided on November 23, 2022. 
 
You asked the Plan to pay for procedure code 87481. 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 providers must report the actual number of units 
provided for each procedure code. 
 
We find that 5 units of CPT code 87481 are not supported in the medical record. The medical record only 
supports 4 units of CPT code 87481. Based on this information, we decided that Medicare rules for coverage of procedure code 87481 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 87481 provided on November 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87581, 87640, 87641, 87651, U0005, 87798 
and 87634 billed for date of service December 15, 2022.  
 
You asked the Plan to pay for procedure codes 87581, 87640, 87641, 87651, U0005, 87798 and 87634. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We find that CPT codes 87581, 87640, 87641, 87651, and U0005 are not supported in the medical record. 
Specifically, a panel was performed and there is a more appropriate singular code for the services. 
 
Medicare rules also say that submitted claims in which the unit of service exceeds the MUE value cannot be 
paid when the MAI value is 3, unless there is evidence justifying the excess units.  
 
In this case, the MUE for CPT code 87798 is 13. The MAI value for this code is 3. You billed 14 units of this 
code, exceeding the MUE. The MUE for CPT code 87634 is 1. The MAI value for this code 3. You billed 2 
units of this code, exceeding the MUE. You did not provide all the required evidence showing that the excess 
units were actually provided, were correctly coded, and were medically necessary. Therefore, we decided that 
the Plan does not have to pay for procedure codes 87581, 87640, 87641, 87651, U0005, 87798 and 87634 
billed for date of service December 15, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
the enrollee requires all the recommended components to meet their mobility, medical, and functional needs in 
their home. The Plan denied your request. The Plan says that although there are three requested power options 
(tilt, recline and elevating leg rests), there is not a medical need to control these power options through the 
joystick. 
 
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 electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are considered medically reasonable 
and necessary in this case. Our physician reviewer found that the enrollee is non-ambulatory and requires a 
power wheelchair for mobility and performing daily activities. They cannot perform pressure relief 
independently due to upper extremity weakness and require a power wheelchair with power tilt and recline for 
adequate pressure relief and positioning. Power elevating leg rests are required for positioning of the lower 
extremities and lower extremity spasticity. Our reviewer found that the complexity of the enrollee's 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. Our physician reviewer also found that these components are required to operate 
3 or more power options on a Group 3 power wheelchair. 
 
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, harness, and expandable controller have been met. 
Therefore, we decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).  
 
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 pre-approve a pontic (D6245) for tooth #26. 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan pre-approved a pontic (D6245) for tooth #20, #22, and #24 on October 12, 2023; therefore, the 
enrollee's benefit for the requested item or service was exhausted on the date of approval of October 12, 2023. 
Therefore, we decided that the Plan does not have to pre-approve a pontic (D6245) for tooth #26.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pulp vitality tests (D0460), the core buildup (D2950) 
for tooth #4 and #21, the pulpal debridement (D3221) for tooth #21, and the gingival irrigation (D4921). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services with x-rays. The Plan denied your request. The Plan says the denial of authorization for these services 
is correct, because the pulp vitality tests, the core buildup, the pulpal debridement, and the gingival irrigation 
are 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
pulp vitality tests (D0460), the core buildup (D2950) for tooth #4 and #21, the pulpal debridement (D3221) for 
tooth #21, and the gingival irrigation (D4921).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 home health physical therapy visits (G0151).  

You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found provided 
records in this case document the enrollee has improved with therapy and is independent with ambulation and 
has been educated on a home exercise program as well as pain management techniques, safety measures and 
techniques to perform activities of daily living. The enrollee has no complaints of pain with treatment. After the 
therapy provided plus the recently approved additional therapy treatments, records do not support that the 
complexity of the enrollee's conditions are such that the skills of a professional therapist are required to achieve 
further improvement in the enrollee's symptoms or functional status. Further utilization of the home exercise 
program appears appropriate at this point. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 7 home health physical therapy visits (G0151).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056) and an abutment 
supported porcelain/ceramic crown (D6058) for tooth #12. 
 
You asked the Plan to pre-approve the dental services. You say that you were not aware of a time frame. You 
say you hope this can be resolved so that you can have your implants done. The Plan denied your request. The 
Plan says your benefit for the requested items or services has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
These services are not covered under the medical benefit; however, the Plan offers a dental benefit in excess of 
Medicare coverage and certain limitations apply. The record shows your benefit for the requested items or 
services was exhausted on May 31, 2023 when the Plan authorized D6056 and D6058 for tooth #7 and #8. 
Therefore, we decided that the Plan does not have to pre-approve a prefabricated abutment (D6056) and an 
abutment supported porcelain/ceramic crown (D6058) for tooth #12.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has 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. You say that all of the codes are medically 
necessary. The Plan denied your request. The Plan says that 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 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 electronic connection. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient is functionally non-ambulatory and requires a power wheelchair for 
mobility and performing daily activities. They cannot perform pressure relief independently due to upper 
extremity weakness and require a power wheelchair with power tilt for adequate pressure relief and 
positioning. There is a history of skin breakdown. Our reviewer found that power elevating leg rests are 
required for positioning of the lower extremities and lower extremity rigidity. The complexity of the patient's 
seating and positioning needs necessitates a more complex group 3 power wheelchair base. Our physician 
reviewer also found that the electronic connection is necessary to operate the group 3 power wheelchair base 
and the power options via a joystick. It is required to operate the power options on a group 3 power wheelchair. 
 
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 have been met. Therefore, we decided that the Plan has 
to pre-approve an electronic connection between wheelchair controller and one power seating system motor 
(E2310).  
 
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 waive the coinsurance for remote physiologic monitoring treatment 
provided on June 27, 2023. 
 
You asked the Plan to waive the coinsurance for remote physiologic monitoring treatment. You say that you 
are requesting reconsideration because you do not agree with the payment you received for the rendered 
services. 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 50% 
coinsurance for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay 50% coinsurance for remote physiologic monitoring treatment. This item/service 
falls within the physician/practitioner services, including doctors office visits 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 $73.36 ($56.13 
allowed amount x 50% = $28.07 and the $45.29 allowed amount [$28.07 + $45.29 = $73.36]). Therefore, we 
decided that the Plan does not have to waive the coinsurance for remote physiologic monitoring treatment 
provided on June 27, 2023.