Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve code L5999. We decided that the Plan does not have to pre-
approve code L5962.  
 
You asked the Plan to pre-approve prosthetic codes L5999 and L5962. The Plan says that the items are not 
primarily medical in nature. 
 
We decided that the Plan has to pre-approve code L5999.  
 
The Plan follows Medicare rules. Medicare rules say that replacement of a prosthesis or prosthetic component 
is covered because of irreparable wear of the device or a part of the device. 
 
We looked at the file and the rules. The documentation shows that the enrollees current foot shell is over 10 
years old and is falling apart. Replacement of a prosthetic component is covered due to irreparable damage. 
Based on this information, we decided that the Medicare rules for coverage have been met. Therefore, we 
decided that the Plan has to pre-approve code L5999.  
 
We also decided that the Plan does not have to pre-approve code L5962. 
 
The Plan follows Medicare rules. Medicare rules say that protective outer surface covering systems are only 
covered under certain indications.  
 
We looked at the file and the rules. The documentation does not show that the enrollee has a need for 
protection against unusually harsh environmental situations where it is necessary to protect the lower limb 
prosthesis beyond the level of protection that is afforded by a basic cover. 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 pre-approve code L5962. 
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied claim and that the services requested are medically necessary. The Plan denied your request. The Plan 
says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the hospital bed provided on July 16, 
2022, to December 16, 2022. 
 
You asked the Plan to waive the coinsurance for the hospital bed. You say that you do not know why the Plan 
did not send these bills back in 2022. 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 20% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the hospital bed. This item/service falls within the durable 
medical equipment and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. You have been asked to pay $18.81, which is 20% coinsurance of the 
allowed amount, for July 16, 2022, and December 16, 2022 ($94.07 allowed amount x 20% coinsurance = 
$18.81). Therefore, we decided that the Plan does not have to waive the coinsurance for the hospital bed 
provided on July 16, 2022, to December 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthotic device. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says the use of this item is considered experimental and investigational. 
 
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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the MyoPro Orthosis is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for this 
patient's condition or in widespread use for this enrollee's condition based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this patient.  There is insufficient evidence in the literature that this device will increase participation in bimanual 
activities. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro orthotic device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on June 14, 2023, to July 21, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you would like 
the Plan to waive the $25 copayment for PT 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 a $25 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $25 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation 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. The total you owe is $300 for PT services ($25 per visit x 12 visits = $300). 
Therefore, we decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit 
provided on June 14, 2023, to July 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that proton therapy is medically necessary. 
The Plan denied your request. The Plan says this is not the standard of care for the enrollee's condition. 
 
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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found proton therapy is an accepted, safe, and effective treatment modality for lung cancer. 
However, it is not clear that proton therapy affords any benefit over intensity-modulated radiation therapy 
(IMRT). There is no plausible reason provided that proton therapy would be more beneficial than standard 
therapy for this 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 proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for the specialist office visit and ultrasound 
guided procedure provided on August 7, 2023. 
 
You asked the Plan to reduce the copayments for the specialist office visit and ultrasound guided procedure. 
You say that you were told there would only be the office visit copayment. 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 $30 
copayment for in-network physician/practitioner services. Your contract with the Plan also clearly says that you 
must pay a $50 copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $30 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services benefit category. You have also been asked to pay $20 for the ultrasound guided 
procedure, which is less than the standard $50 copayment. This item/service falls within the outpatient 
diagnostic tests and therapeutic services benefit category. You have been asked to pay a total of $50 ($30 
copayment + $20 copayment = $50). 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 reduce the copayments for the specialist office 
visit and ultrasound guided procedure provided on August 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on December 15, 2022, billed 
with evaluation and management (EM) code 99223. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
We asked our physician 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the medical decision making supports 
moderate complexity. There is a more specific code to report for service provided. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on December 15, 2022, billed with evaluation 
and management (EM) code 99223.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits provided from December 6, 2022, to January 5, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient services. You say that the provider is in-network. You also say that 
this should be reprocessed and paid. The Plan denied your request. The Plan says the provider was not in-
network for the dates of service in this case. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for office visits provided from December 6, 2022, to January 5, 2023, by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cushion nasal mask (A7032) and sales tax (S9999), 
purchased on March 27, 2023. 
 
You asked the Plan to pay for the cushion nasal mask and sales tax. You say that the items should be covered. 
The Plan denied your request. The Plan says this was purchased through a provider that is not enrolled in 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the cushion nasal mask (A7032) and 
sales tax (S9999), purchased on March 27, 2023.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0105 billed for date of service April 18, 2023. 
 
You asked the Plan to pay for the billed services. You say that the colonoscopy is needed due to past medical 
history. The Plan denied your request. The Plan says that the diagnosis is inconsistent with the procedure. 
 
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 G0105 is colorectal cancer screening; colonoscopy on 
individual at high risk. We find that CPT code G0105 is supported in the medical record. The case file shows 
that the colonoscopy was billed with diagnosis code Z86.010, defined as a history of colon polyps. The rules 
say that a personal history of polyps indicates an individual is at high risk for developing colorectal cancer. 
Based on this information, we decided that Medicare rules for coverage have been met. Therefore, we decided 
that the Plan has to pay for procedure code G0105 billed for date of service April 18, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69209 billed for date of service May 24, 
2023. 
 
You asked the Plan to pay for the billed services. You say that no modifier is needed. The Plan denied your 
request. The Plan says an anatomical modifier was not used. 
 
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 69209 is removal impacted cerumen using 
irrigation/lavage, unilateral. We find that CPT code 69209 is not supported. Code 69209 was not billed with a 
modifier suitable for payment. The code is not consistent with the billed diagnosis, H61.23, defined as 
impacted cerumen, bilateral. The records do show that both ears were lavaged due to cerumen impaction. There 
is an appropriate modifier available to indicate bilateral services were provided. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 69209 billed for date of service May 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
on February 14, 2023, through March 13, 2023. 
 
You asked the Plan to pay for the water circulating heat pad with pump. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if code E0215 or E0217 is provided it will be 
denied as not reasonable and necessary 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the water circulating heat pad with pump (E0217) provided on February 14, 2023, 
through March 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fluid circulating cold pad with pump (E0218) provided on 
March 22, 2023, through April 12, 2023. 
 
You asked the Plan to pay for A fluid circulating cold pad with pump. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of A fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for a fluid circulating cold pad with pump (E0218) provided on March 22, 2023, through 
April 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Altru Dx UTI-ABR Molecular Test Panel provided on 
June 30, 2023, and billed 87481, 87798, and 87801. 
 
You asked the Plan to pay for the Altru Dx UTI-ABR Molecular Test Panel. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says this testing should be billed with a single 
panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the Altru Dx UTI-ABR Molecular Test Panel have not been met. Therefore, we decided that the Plan does not have to pay for the Altru Dx UTI-ABR 
Molecular Test Panel provided on June 30, 2023, and billed 87481, 87798, and 87801.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D7953, D6010, D5110, and D6057). 
 
You asked the Plan to pre-approve the dental services (D7953, D6010, D5110, and D6057). You say that you 
would like to request reconsideration of the denied dental services and that the services requested are medically 
necessary. The Plan denied your request. The Plan says the dental services (D7953, D6010, D5110, and 
D6057). requested 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 pre-approve the 
dental services (D7953, D6010, D5110, and D6057).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vasopneumatic compression unit (VCU) (E0650) and 
related accessories (E0673, E0666, 97760), provided on February 16, 2023, through March 7, 2023. 
 
You asked the Plan to pay for the VCU and related accessories.. You say that the items were medically 
necessary. The Plan denied your request. The Plan says pneumatic compression devices are not covered by 
Medicare for the treatment of deep vein thrombosis. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for the vasopneumatic compression unit (VCU) (E0650) and related accessories (E0673, E0666, 97760), provided on February 16, 2023, through March 
7, 2023.