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

 
We decided that the Plan does not have to pay for compression stockings x2 identified with code A6530 
provided on October 18, 2022. 
 
You asked the Plan to pay for the compression stockings (A6530) x2. You say that you do not agree with the 
denial of the requested items. The Plan denied your request. The Plan says the criteria for compression 
stockings has not been met. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing. 
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings x2 identified with code A6530 that were issued on October 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service February 14, 
2023.   
You asked the Plan to pay for procedure code 88341. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 23 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 88341 
billed for date of service February 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia in conjunction with operative or surgical 
procedures (D9215) provided on April 12, 2023. 
 
You asked the Plan to pay for local anesthesia in conjunction with operative or surgical procedures (D9215). 
You say that you spoke with someone from the Plan, and they think this was denied because it is out-of-
network. You also say that you have out-of-network coverage. The Plan denied your request. The Plan says this 
service is not covered under the 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 pay for local 
anesthesia in conjunction with operative or surgical procedures (D9215) provided on April 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids purchased on December 2, 
2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were rendered by an out-of-network provider, without prior authorization.  
 
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 issue reimbursement 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 at issue in this appeal. The Plan did not pre-approve the items at issue.   
 
 
 
We found no exception that would require the Plan to issue reimbursement for these items. Therefore, we 
decided that the Plan does not have to issue reimbursement for the hearing aids purchased on December 2, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dual marker light fender assembly (K0108). 
 
You asked the Plan to pre-approve the fender light assembly. You say that the wheelchair repairs are being 
denied and the enrollee's life depends on the wheelchair. The Plan denied your request. The Plan says the 
fender light assembly does not serve a medical purpose and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   

We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the fender light assembly have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the dual marker light fender assembly (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) provide on April 
12, 2023. 
 
You asked the Plan to pay for a determination of refractive state (92015). You say that this was medically 
necessary. The Plan denied your request. The Plan says tests for the determination of refractive state may be 
covered by the plan, but only when performed as part of a routine vision exam. 
 
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 it is part of the routine examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that routine (refractive) eye examinations are 
limited to one examination every two calendar years. The Plan rules also say that Original Medicare does not 
cover routine eye examinations (eye refractions) for eyeglasses/contacts. The record shows that this 
determination of refractive state was not a routine examination but a medical/diagnostic examination. Based on 
this information, we decided that the Plan's rules for coverage of a determination of refractive state (92015) 
have not been met. Therefore, we decided that the Plan does not have to pay for a determination of refractive 
state (92015) provide on April 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the 
panoramic radiographic image (D0330) provided on March 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
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 your benefit for the services provided was exhausted on date of service October 20, 2021.   
 
 
 
Specifically, a comprehensive oral evaluation is covered once every three years. You previously received this 
service on October 20, 2021, less than three years prior, which was paid for by the Plan. Therefore, you have 
exhausted the allowable benefit for this service. Additionally, a panoramic radiographic image is covered once 
every five years. You previously received this service on October 20, 2021, less than five years prior, which 
was paid for by the Plan. Therefore, you have exhausted the allowable benefit for this service. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the panoramic 
radiographic image (D0330) provided on March 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that in consideration of the enrollee's prior medical 
history, active comorbidities, and risk for medical instability while increasing activity, the IRF setting is the 
most appropriate to reach the desired outcomes. 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 enrollees 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 enrollee may have a need for physical 
therapy 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 the 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 an IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 22, 2022, 
to March 22, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that there are no issues with the 
NOA. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 22, 2022, to 
March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve the electronic connection, harness, and expandable controller. You say that 
the items are medically necessary. The Plan denied your request. The Plan says that the items are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items are considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee is non-ambulatory and requires a power 
wheelchair for mobility and performing her basic daily activities. She cannot perform pressure relief 
independently due to upper extremity weakness limited range of motion and requires a power wheelchair with 
power tilt and recline for adequate pressure relief and positioning. She requires power elevating leg rests for 
positioning of her lower extremities and lower extremity spasticity. The complexity of her seating and 
positioning needs necessitates a more complex group 3 power wheelchair base. The expandable controller with 
harness and electronic connection are necessary to operate the group 3 power wheelchair base and the three 
power options via a joystick. These components are required to operate 3 or more power options on a group 3 
power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the electronic connection, harness, and expandable controller have been met. 
Therefore, we decided that the Plan has to pre-approve the electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on 
March 29, 2023. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
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 your benefit for the service provided was exhausted on date of service October 16, 2018.  
  
 
 
 
Specifically, the Plans contract states that one full mouth x-ray is covered every five years. You previously 
received this service on October 16, 2018, less than five years ago, which was paid for by the Plan. Therefore, 
you have exhausted the allowable benefit for this service. Therefore, we decided that the Plan does not have to 
pay for the panoramic radiographic image (D0330) provided on March 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental crowns-porcelain fused to high noble metal 
(D2750 x 2) provided on January 20, 2023. 
 
You asked the Plan to pay for these dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these items are not a covered benefit.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental items provided are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
crowns-porcelain fused to high noble metal (D2750 x 2) provided on January 20, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve INGREZZA. 
 
You asked the Plan to pre-approve the medication. You say that this is 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 INGREZZA.   
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the vision services provided on March 22, 
2023. 
 
You asked the Plan to waive the copayment for the vision services. You say that you have met your maximum 
out-of-pocket amount. 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 $10 
copay for physician services to diagnose and treat diseases and conditions of the eye. The record shows you had not met your maximum out-of-pocket amount prior to this service. You have been 
asked to pay a $10 copayment for the vision services. This item/service falls within the vision 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 the vision services provided on March 22, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on January 
12, 2023. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this test is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on January 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator (E0466). 
 
You asked the Plan to pre-approve a home mechanical ventilator. 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. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide continuous positive airway pressure (CPAP) or bi-level CPAP therapy will be denied as not reasonable and 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 a home mechanical ventilator. Our 
reviewer says that the item is not medically necessary. Our physician reviewer found the enrollee could be 
treated with a BiPAP machine with AVAPS capability and failure of such a device has not been documented. 
 
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 home mechanical ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home mechanical ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on February 1, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on February 1, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of an upper extremity joint. 
 
You asked the Plan to pre-approve the MRI. You say that the enrollee has symptoms of cervical nerve root 
irritation and rotator cuff tendon dysfunction. The Plan denied your request. The Plan says that the criteria for 
coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the enrollee has done conservative therapy, and 
an ultrasound of the left shoulder revealed bursitis and tendinopathy. Due to the conservative treatment and an 
abnormal ultrasound the requested MRI Left shoulder should be approved. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of an upper extremity joint.  
 
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.