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

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided on March 
14, 2023, to March 20, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the claim should not have denied, 
and you are asking the Plan to review medical records and process the claim for payment. The Plan denied your 
request. The Plan says the requested PCD is not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0675 to treat peripheral arterial disease 
is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided on March 14, 2023, to March 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant at surgery for a integumentary system repair 
(13160). 
 
You asked the Plan to pay for the assistant at surgery for a integumentary system repair . You say that the 
service should be covered. The Plan denied your request. The Plan says the assistant at surgery was not 
medically necessary for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 13160. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the assistant at surgery for a integumentary system repair  have not been met. Therefore, we decided that the Plan 
does not have to pay for the assistant at surgery for a integumentary system repair (13160).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need this level of care. The Plan 
denied your request. The Plan says your needs can be safely managed at the current facility until they are more 
stable for transfer to another level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you do not require services at the LTACH that are not already available at the acute 
care hospital. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wireless capsule endoscopy (91110). 
 
You asked the Plan to pre-approve a wireless capsule endoscopy. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not medically necessary because the records do not show results 
from a colonoscopy or EGD that show they fail to reveal a source of bleeding. 
 
The Plan must follow Medicare rules. Medicare rules say that use of wireless capsule endoscopy is indicated 
only if EGD and colonoscopy have been done and failed to identify a bleeding source.  
 
We looked at the file and Medicare rules. Specifically, the medical records show that the enrollee has not had 
an EGD or colonoscopy. Based on this information, we decided that Medicare rules for coverage of a wireless 
capsule endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
wireless capsule endoscopy (91110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a remote interrogation device evaluation provided on May 
09, 2023. 
 
You asked the Plan to pay for a remote interrogation device evaluation. You say that this is supported in the 
records. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a remote interrogation 
device evaluation provided on May 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services (97810, 97811), manual therapy 
techniques (97140) and infrared therapy (97026) provided on June 19, 2023. 
 
  You asked the Plan to pay for the acupuncture services (97810, 97811), manual therapy techniques (97140) and 
infrared therapy (97026) . You say that acupuncture services are covered when diagnosed with chronic low 
back pain. You say that the claim should be reprocessed correctly. The Plan denied your request. The Plan says 
the provider has not submitted any clinical records to support the medical necessity of the services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the acupuncture services (97810, 
97811), manual therapy techniques (97140) and infrared therapy (97026) have been met. Specifically, after 
multiple attempts, no medical records were received by the Plan. Therefore, we decided that the Plan does not 
have to pay for the acupuncture services (97810, 97811), manual therapy techniques (97140) and infrared 
therapy (97026) provided on June 19, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the cervical spine, and 
a computed tomography (CT) scan of the head or brain provided on August 30, 2022. 
 You asked the Plan to pay for a CT scan of the cervical spine and a CT scan of the head or brain. You say that 
the claim should be reprocessed. The Plan denied your request. The Plan says Original Medicare is responsible 
for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a computed tomography (CT) scan of the cervical spine, and 
a computed tomography (CT) scan of the head or brain provided on August 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osseous surgery (D4260 x 3). 
 
You asked the Plan to pre-approve the dental services. You say that your benefit book does not list specific 
procedures, but it does indicate you have coverage for oral surgery. The Plan denied your request. The Plan 
says this service is not a covered benefit 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
osseous surgery (D4260 x 3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported to crown (D6058) for tooth #19. 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied service and 
you have $3,000 available to finish the dental procedure. The Plan denied your request. The Plan says your 
dental maximum benefit for the year 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 Plans 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 paid $1,600 for dental services on April 28, 2023. On August 16, 2023, the Plan paid $500 for 
dental services. On August 9, 2023, the Plan pre-approved $1,125 for dental services. For the year of 2023 the 
Plan covered $3,000 ($1,600 paid + $500 paid + $1,125 approved) for dental services; therefore, your annual 
dental maximum benefit for the year of 2023 was exhausted on the date of approval of August 9, 2023. 
Therefore, we decided that the Plan does not have to pre-approve an abutment supported to crown (D6058) for 
tooth #19.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve ablation (64624). 
 
You asked the Plan to pre-approve genicular nerve ablation. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 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 there is insufficient literature to support the safety and efficacy, as defined by 
Medicare rules, of the requested service. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.  The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve ablation (64624).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
for medical appointments. The Plan denied your request. The Plan says you have utilized the maximum number 
of transportation trips allowed per year. 
 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 72 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 additional routine transportation trips (A0120).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation and ground mileage provided on 
May 24, 2023. You asked the Plan to pay for the ambulance services. You say that the submitted records provide the medical 
necessity of the transport. The Plan denied your request. The Plan says the enrollee was transported from a 
physician's office and then transported to another physician office. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for ambulance transportation and ground mileage 
provided on May 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit for the evaluation provided on July 
12, 2023. 
 
You asked the Plan to pay for a home or residence visit for the evaluation. You say that the services were 
medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home or residence visit 
for the evaluation provided on July 12, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external mobile cardiovascular telemetry provided on 
May 22, 2023. 
 
You asked the Plan to pay for the external mobile cardiovascular telemetry. You say that the service was 
medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the external mobile 
cardiovascular telemetry provided on May 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Fungal Infection Polymerase Chain Reaction (PCR) 
Panel (87481 and 87798) provided on June 23, 2023. 
 
You asked the Plan to pay for the Fungal Infection Polymerase Chain Reaction (PCR) Panel (87481 and 
87798). You say that the provided Fungal Infection PCR Panel was medically necessary.  The Plan denied your 
request. The Plan says the provided Fungal Infection PCR Panel was 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 pay for the Fungal Infection Polymerase Chain 
Reaction (PCR) Panel (87481 and 87798). Our reviewer says that the provided Fungal Infection PCR Panel 
was not medically necessary. Our physician reviewer found the PCR testing for this enrollees right hallux 
toenail was not medically reasonable or necessary. It is well established in the medical documentation that this 
enrollee is suffering with thick painful toenails that demonstrate subungual detritus. A toenail specimen was 
taken and sent for PCR testing to evaluate for pathogens. The longstanding standard of care for the evaluation 
of fungus in toenails is the performance of both potassium hydroxide (KOH) and fungal culture on a toenail 
specimen. These laboratory tests are inexpensive, sensitive, and specific. It is unclear as to why this enrollees 
toenail required PCR testing as compared to KOH and fungal culture. Therefore, the PCR testing of this 
enrollees right hallux toenail was not medically reasonable or necessary at this time. 
 
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 Fungal Infection Polymerase Chain Reaction (PCR) Panel (87481 and 
87798) have not been met. Therefore, we decided that the Plan does not have to pay for the Fungal Infection 
Polymerase Chain Reaction (PCR) Panel (87481 and 87798) provided on June 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on May 14, 2023. 
 
You asked the Plan to pay for hearing aids. You say that a Plan rep told you that you needed to submit the 
claim for reimbursement for hearing aids on the computer online account. You also say that you are appealing 
and submitting the records. The Plan denied your request. The Plan says there is no coverage for hearing aids 
when received from a provider other than the Plan hearing providers. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are obtained from a Plan hearing provider.  
 
 
  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
hearing aids provided on May 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each cataract surgery provided on June 23, 
2023, to July 07, 2023. 
 
You asked the Plan to waive the copayment for each cataract surgery. You say that you received a pre-surgical 
estimate that stated you owe a $0 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 $420 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $420 copayment for each cataract surgery. This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities 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 amount you owe is $840 
($420 copayment x 2 surgeries = $840). Therefore, we decided that the Plan does not have to waive the 
copayment for each cataract surgery provided on June 23, 2023, to July 07, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on May 
19, 2023. 
 
You asked the Plan to pay for the dental service. You say that you were not aware that the x-rays were covered 
once every 5 years. 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 Plans 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 paid for a panoramic radiographic image (D0330) on November 11, 2022; therefore, your 
benefit for the requested item or service was exhausted on the date of service of November 11, 2022. 
Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) 
provided on May 19, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Positive Airway Pressure (PAP) titration study. 
 You asked the Plan to pre-approve a PAP titration study. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that sleep studies are covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a PAP titration study. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found in the absence of any severe 
health conditions using an auto-titrating PAP (APAP) machine at home is appropriate to treat OSA. Research 
shows that tests done in labs and at home give the same outcome when someone has OSA. The review has 
determined that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
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 PAP titration study have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Positive Airway Pressure (PAP) titration study.