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

 
We decided that the Plan has to pre-approve a microprocessor knee (L5828, L5845, L5848, L5856). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this exceeds the enrollee's needs and is not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. 
 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the medical records go above and beyond in demonstrating the enrollee's K3 level potential. The 
enrollee has specific needs for these requested components. The enrollee will be able to ambulate at the K3 
level potential without limitation if equipped with the right prosthesis matching their functional level. The 
enrollee has resumed independent living and community ambulation using his existing prosthesis, whose 
components were designed to a K2 standard in 2017. His care team judges that he has since advanced to K3-
level potential. The existing socket is ill-fitting and the 2017 components are worn out, beyond warranty, and 
not meeting the enrollee's functional needs due to a lack of stability/reliability. A lesser device would not meet 
the enrollee's functional needs, and would amount to substandard care.  
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 services have been met. Therefore, we decided that the Plan has to pre-
approve a microprocessor knee (L5828, L5845, L5848, L5856).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound Proteus molecular polymerase chain reaction 
(PCR) panel provided on August 10, 2023, and billed with codes 87481 and 87798. 
 
You asked the Plan to pay for the wound Proteus molecular PCR 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 wound Proteus molecular PCR panel 
have not been met. Therefore, we decided that the Plan does not have to pay for the wound Proteus molecular 
polymerase chain reaction (PCR) panel provided on August 10, 2023, and billed with codes 87481 and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 13, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the outpatient service. You say that this should be reprocessed and paid. The 
Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 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 office visit provided on January 13, 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 belt, strap, sleeve, garment, or covering, any type 
(A4467) provided May 23, 2023. 
 
You asked the Plan to pay for the orthosis. You say that you are appealing because the sleeve that was provided 
to you was not supportive enough for your injured knee. The Plan denied your request. The Plan says this item 
is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the 
belt, strap, sleeve, garment, or covering, any type (A4467) provided May 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered vehicle with a weight capacity up to and 
including 300 pounds (K0806). 
 
You asked the Plan to pre-approve a powered vehicle with a weight capacity up to and including 300 pounds. 
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. A power wheelchair (K0823) has already been 
approved. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices 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 powered vehicle with a weight 
capacity up to and including 300 pounds. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found you have impaired mobility due to lumbar spinal stenosis and neuropathy. You have 
difficulty ambulating and requires assistance with mobility. However, the mobility evaluation and the 
documentation does not provide your level of mobility as well as graded motor strength and range of motion in 
the upper and lower extremities. It is unclear why you cannot use a cane or walker or propel a manual wheelchair based on the physical examination findings. Your level of function with transfers and seating and 
standing balance are note provided and it is not explained why you cannot utilize a power scooter and requires 
a group 2 power mobility device. Therefore, the group 2 power wheelchair is not medically necessary. 
 
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 powered vehicle with a weight capacity up to and including 300 pounds have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a powered vehicle with a 
weight capacity up to and including 300 pounds (K0806).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for office visits provided on May 2, 2023 and  
May 25, 2023. 
 
You asked the Plan to reimburse you for the office visits. You say that the services were medically necessary. 
The Plan denied your request. The Plan says naturopath services and not covered under any condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to reimburse you for office visits provided on May 2, 2023 and May 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4239 billed for date of service June 6, 
2023. 
 
You asked the Plan to pay for procedure code A4239. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code A4239 is considered bundled/excluded and not separately 
payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code A4239 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4239 is excluded/not separately payable. Based on this information, we decided that 
Medicare rules for coverage of procedure code A4239 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code A4239 billed for date of service June 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit for the destruction of a premalignant lesion 
provided on May 23, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that you are appealing the denial. The Plan denied your 
request. The Plan says their original decision to deny payment was correct. 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 an office visit for the destruction of a premalignant 
lesion provided on May 23, 2023, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
July 24, 2023, to July 26, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that the enrollee was 
advised by their physician to go to the emergency room. 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 $125 
copayment for emergency care. 
 
You have been asked to pay a $125 copayment for an emergency room (ER) visit. This item/service falls 
within the emergency 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 copayment for an 
emergency room (ER) visit provided on July 24, 2023, to July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, blood draw and laboratory testing provided 
on November 11, 2022. 
 
You asked the Plan to pay for the physician services. You say that your family member referred you to this 
provider. You say that you were advised this provider does not take insurance. You also say that a Plan 
representative advised that 70% would be covered when you see your primary doctor. The Plan denied your 
request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment 
cannot be made for services performed by a provider that has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office 
visit, blood draw and laboratory testing provided on November 11, 2022.  Your complaint about being misled by a Plan representative is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opzelura. 
 
You asked the Plan to pre-approve the medication. You say that other medications have not resulted in durable 
control. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under 
the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Opzelura.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Memantine. 
 
You asked the Plan to pre-approve Memantine. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Memantine.  Benefits for Memantine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen equipment and continuous positive 
airway pressure (CPAP) supplies provided on May 28, 2023, to July 10, 2023. 
 
You asked the Plan to waive the coinsurance for oxygen equipment and continuous positive airway pressure 
(CPAP) supplies. You say that you say that you dont agree with the amount the plan is charging. 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 (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for oxygen equipment and continuous positive airway pressure 
(CPAP) supplies. This item/service falls within the durable medical equipment (DME) 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. The 
total amount you owe is $129.16, which is 20% coinsurance of the allowed amount for each item. Therefore, 
we decided that the Plan does not have to waive the coinsurance for oxygen equipment and continuous positive 
airway pressure (CPAP) supplies provided on May 28, 2023, to July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 13, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the physician service. You say that you were referred to this provider by your 
primary care physician. You also say that you would like a one-time exception should be made. The Plan 
denied your request. The Plan says services received out-of-network are 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 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 office visit provided on June 13, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SIJ RFA. 
 
You asked the Plan to pre-approve a SIJ RFA. You say that the enrollee can benefit from the requested 
procedure. The Plan denied your request. The Plan says the requested procedure is not supported by research to 
treat sacroiliac pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a SIJ RFA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has sacroiliac pain. Coverage for the requested procedure 
is not available under the rule that states the requested procedure is not considered reasonable and necessary. 
The requested service is not recommended as the elements of the coverage criteria are not satisfied. 
 
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 SIJ RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a SIJ RFA.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service March 19, 
2023. 
 You asked the Plan to pay for procedure code 93010. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 93010 is bundled into payment for code 
25605. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93010 
is a column II code to column I code 25605. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93010 billed for date of service March 19, 2023.
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 reconsideration based on the records 
submitted. The Plan denied your request. The Plan says admission to an IRF is not medically necessary.  
 
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 that 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 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 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. There is 
not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Medically necessary care can be provided in a different 
level of care.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided from April 25, 2023, to July 5, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physician services. You say that the referral to the specialist was denied. You 
also say that you have known this provider for 15 years. The Plan denied your request. The Plan says prior 
authorization was not obtained. 
 
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 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 office visits provided from April 25, 2023, to 
July 5, 2023, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve the medication. The Plan denied your request. The Plan says the medication 
is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ozempic.  Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.