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

 
We decided that the Plan does not have to pay for a group 2 standard power wheelchair (K0823). 
 
You asked the Plan to pay for a group 2 standard power wheelchair. The Plan denied your request. The Plan 
says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity. Medicare 
rules also say if the treating practitioner does not conduct the face-to-face encounter or write the SWO for the 
PMD base item, the claim will be denied as statutorily noncovered. 
 
The record does not contain a valid physician order, which is required for coverage. Therefore, we decided that 
the Plan does not have to pay for a group 2 standard power wheelchair (K0823).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lens, the polycarbonate lens, the photo 
plastic, the anti-reflective coating, and the frames. provided on May 13, 2023. 
 
You asked the Plan to pay for the progressive lens, the polycarbonate lens, the photo plastic, the anti-reflective 
coating, and the frames. You say that you cannot afford the denied amount. The Plan denied your request. The 
Plan says the eyewear is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when eyeglasses and frames or contact lenses up to the plan allowance 
amount. 
 
We looked at the file and the Plan's rules. The Plan paid for contact lens fitting on May 12, 2023, and for the 
disposable contact lenses on May 13, 2023. The Plan will only pay for either glasses or contact lenses. 
Therefore, the eyeglasses are not covered. Based on this information, we decided that the Plan's rules for 
coverage of the progressive lens, the polycarbonate lens, the photo plastic, the anti-reflective coating, and the 
frames have not been met. Therefore, we decided that the Plan does not have to pay for the progressive lens, 
the polycarbonate lens, the photo plastic, the anti-reflective coating, and the frames. provided on May 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve genicular nerve block. You say that conservative measures have been 
exhausted. The Plan denied your request. The Plan says this procedure is experimental/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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered an experimental/investigational procedure and is the subject of 
ongoing clinical trials. 
 
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 block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 26, 2023, billed with 
codes G0452, 81270, 81279, 81338, and 81219. 
 
You asked the Plan to pay for the genetic testing billed. 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. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 26, 2023, billed with codes G0452, 81270, 81279, 81338, and 81219.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 01992 billed with diagnosis codes 
M48.50XA and M80.08XA provided on January 19, 2023. 
 
You asked the Plan to pay for procedure code 01992. 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. The rules say that health plans, physicians, hospitals, and other health 
care providers must comply with the Official International Classification of Disease, 10th Edition, Clinical 
Modification (ICD-10-CM) Coding Guidelines. 
 
We looked at the file and Medicare rules. In this case, coding guidelines state that a type 1 Excludes note is a 
pure excludes note. It means "Not Coded Here!" An Excludes1 note indicates that the code excluded should 
never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two 
conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. 
Diagnosis codes M48.50XA and M80.08XA should not be reported together. Therefore, we decided that the 
Plan does not have to pay for procedure code 01992 billed with diagnosis codes M48.50XA and M80.08XA 
provided on January 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite test strips (A4253). 
 
You asked the Plan to pre-approve Freestyle Lite test strips. You say that you disagree with the denial. The 
Plan denied your request. The Plan says only the preferred brand products listed in the EOC are covered.  
 
 
 The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for Freestyle Lite test strips. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite 
test strips (A4253).
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 87798-XU. We decided 
that the Plan does not have to pay for the services described by procedure code(s) 87481 and 87653.  
 
You asked the Plan to pay for procedure codes 87798, 87481 and 87653 billed for date of service September 
12, 2022. You say that these codes are supported in the records provided. The Plan says that these codes are not 
supported for separate reporting. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 87798-XU.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, code 87798 was billed with modifier XU, which is able to bypass 
the NCCI edit applied in this case. However, it does not appear that the Plan performed a review of the use of 
this modifier to verify whether this service may be separately reported. In addition, the Plan did not include any 
medical records to allow for a separate review of this modifier. The Plan has not substantiated their denial of 
code 87798 with a complete review and supporting documentation. Therefore, we decided that the Plan has to 
pay for the services described by procedure code(s) 87798-XU.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 87481 
and 87653. 
 
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 codes 
87481 and 87653 are column II codes to column I code 87801. These services have not been billed with an 
appropriate modifier to bypass the edit. Based on this information, we decided that Medicare rules for coverage 
of the services described by procedure code(s) 87481 and 87653 have not been met. Therefore, we decided that 
the Plan does not have to pay for the services described by procedure code(s) 87481 and 87653. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic shoes, shoe inserts and a shoe lift, wedge 
(L3020, L3224, L3310). 
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee was born with several deformities 
and one of them is that one leg is longer than the other and is making her quality of living a problem. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve 
orthopedic shoes, shoe inserts and a shoe lift, wedge (L3020, L3224, L3310).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing the refraction and the medical eye 
examination provided on October 11, 2022. 
 
You asked the Plan to waive the cost sharing the refraction and the medical eye examination. You say that you 
were not aware or told up-front that this would be a medical procedure. 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 10% of 
the approved amount, after you meet your annual deductible and a $20 copayment for diagnosis and treatment 
of conditions of the eye.  
 
You have been asked to pay $1.50 which is 10% of the allowed amount for the refraction. The allowed amount 
is $15.01. ($15.01 x 10% = $1.50). You have also been asked to pay a $20 copayment for the medical eye 
examination. The refraction falls within the determination of refractive state benefit category. The medical eye 
examination falls within the vision care. The records show diagnosis of cataracts, allergic conjunctivitis and 
long-standing ptosis, which makes the examination medical in nature. 
 
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 cost sharing the refraction and the medical eye examination provided on 
October 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120), and 
prophylaxis - adult (D1110) provided on January 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that you apologize for going out-of-network but the 
in-network dental provider was a hindrance for you as you are a senior citizen. You also say that using an in-
network provider would also be considered a new patient requiring more time to be in the system to be seen by 
a dentist. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation - established patient (D0120), and prophylaxis - adult (D1110) provided on 
January 31, 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 November 20, 2022, through December 22, 2022. 
 
You asked the Plan to pay for the water circulating heat pad with pump. You say that the item was medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that it has not been established that a moist electric 
heating pad (E0215) or water circulating heat pad with pump (E0217) is reasonable and necessary compared to 
a standard electric heating pad (E0210); therefore, if code E0215 or E0217 is provided it will be denied as not 
reasonable and necessary. You can find this information in the Local Coverage Determinations (LCD): L33784 
Heating Pads and Heat Lamps. 
  
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 November 20, 2022, 
through December 22, 2022.
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 these services are medically necessary. 
The Plan denied your request. The Plan says the enrollee is currently receiving medically necessary 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 the enrollee is currently receiving all indicated care in 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart with 
evaluation of blood vessel calcium. 
 
You asked the Plan to pre-approve the CT scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says they do not have medical records to determine if the services are medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 the CT scan. Our reviewer says that the 
CT scan is not medically necessary. Our physician reviewer found the enrollee does not meet the criteria for the 
requested CT scan. A CT scan with coronary calcium scoring is only indicated in enrollees with a moderate 10-
year risk of atherosclerotic events which the documentation provided does not show. Therefore, the requested 
CT scan cannot be approved 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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the heart with evaluation of blood vessel calcium.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humira pen. 
 
You asked the Plan to pre-approve Humira pen. You say that the services ae medically necessary. 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 Humira pen.  Benefits for Humira pen 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: Favorable

 
We decided that the Plan has to pre-approve Zirabev. 
 
You asked the Plan to pre-approve the drug. You say that the enrollee is doing chemo and the medication is 
needed.  The Plan denied your request. The Plan says that Zirabev is 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 drug. Our reviewer says that 
Zirabev is medically necessary. Our physician reviewer found that the requested use of Zirabev is FDA-
approved. Zirabev is also safe and effective and otherwise reasonable and necessary for the 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 the drug have been met. Therefore, we decided that the Plan has to pre-approve 
Zirabev.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on April 10, 2023. 
 You asked the Plan to pay for the ambulance services. You say that the services should be covered by 
Medicare. 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 the ambulance services provided on April 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99205) a corneal topography (92025) 
and an internal eye photography (92285) with an ophthalmologist to be provided by an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve an office visit with an ophthalmologist. You say that the requested provider 
is closer to your home compared to the network provider. The Plan denied your request. The Plan says you 
must receive services from a network provider. There are network providers available. 
 
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 
an office visit (99205) a corneal topography (92025) and an internal eye photography (92285) with an 
ophthalmologist to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for platelet rich plasma injection provided on May 01, 2023. 
 
You asked the Plan to pay for the injection. You say that the claim should be reprocessed. The Plan denied 
your request. The Plan says a platelet rich plasma injection is a non-covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that all platelet rich plasma injections and/or 
applications as a means of managing musculoskeletal injuries and/or joint conditions are non-covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pay for 
platelet rich plasma injection provided on May 01, 2023.