Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve allograft (20930, 22800). 
 
You asked the Plan to pre-approve allograft. 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 allograft. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found BMP is not FDA approved for use in the posterior lumbar spine. It is experimental. Iliac crest 
autograft is the gold standard. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of allograft have not been met. Therefore, we decided that the Plan does not have 
to pre-approve allograft (20930, 22800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99223) 
rendered on January 24, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is "Initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded." 
 We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that no records for 1/24/2023 are 
identified for review. As such, the billing for 1/24/2023 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for evaluation and management services (procedure code 99223) rendered on January 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a folding walker with seat attachment (E0143, E0156). 
 
You asked the Plan to pre-approve a walker with seat attachment. You say that the walker you currently have 
needs to be replaced as its busted and the brakes do not work. The Plan denied your request. The Plan says 
records show that you were provided with a walker on July 9, 2020, and on April 1, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
 
 
 The item being requested shows to be for replacement of an identical or nearly identical item, due to wear. The 
case file shows that the existing equipment is less than 5 years old. This means that replacement of this 
equipment due to wear is not covered at this time. Therefore, we decided that the Plan does not have to pre-
approve a folding walker with seat attachment (E0143, E0156).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. The Plan 
denied your request. The Plan says that although there are three requested power options (tilt, recline and 
elevating leg rests), there is not a medical need to control these power options through the joystick. 
 
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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are considered medically reasonable 
and necessary in this case. Our physician reviewer found the patient is non-ambulatory and requires a power 
wheelchair for mobility and performing daily activities. They cannot perform pressure relief independently due 
to upper extremity weakness and require a power wheelchair with power tilt and recline for adequate pressure 
relief and positioning. Power elevating leg rests are required for positioning of the lower extremities and lower 
extremity spasticity. Our reviewer found that the complexity of the patients 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. Our physician reviewer also found that 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 an electronic connection, harness, and expandable controller have been met. 
Therefore, we decided that the Plan has to pre-approve an 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve hyperbaric oxygen (HBO) under pressure, full body chamber, per 
30-minute interval (G0277x80) and physician attendance and supervision of hyperbaric oxygen therapy, per 
session (99183x20). 
 
You asked the Plan to pre-approve HBO therapy. You say that the enrollee needs this procedure. The enrollee 
is high-risk to prevent amputation. This is a life-threatening process, and any addition delay will put the limb at 
higher risk. The Plan denied your request. The Plan says that the records do not show that the enrollee's skin 
graft is compromised, but rather shows dead tissue suggesting a failed graft which would not respond to HBO 
therapy. 
 
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 HBO therapy. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a compromised skin graft. Hyperbaric oxygen therapy (HBOT) is necessary for 
salvage therapy for the graft and is indicated for best practice. The enrollee does meet criteria and should 
undergo HBOT per recommended indications.  Hence, meets criteria for HBOT with compromised graft. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy have been met. Therefore, we decided that the Plan has to pre-
approve hyperbaric oxygen (HBO) under pressure, full body chamber, per 30-minute interval (G0277x80) and 
physician attendance and supervision of hyperbaric oxygen therapy, per session (99183x20).  
 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
from February 8, 2023, to February 28, 2023. 
 
You asked the Plan to waive the copayment for SNF care. You say that the circumstances necessitating an 
extended stay were out of your control. 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 $0 copayment each day for Medicare-covered days 1 to 20 and a $196 copayment each day for Medicare-covered 
days 21 to 55 for skilled nursing facility (SNF) care.  
 
You have been asked to pay a $392 copayment ($196x2) for days 21 and 22 of SNF care. This item/service 
falls within the skilled nursing facility (SNF) 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 skilled nursing facility (SNF) care provided from February 8, 2023, to February 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for general anesthesia for each subsequent 15 minute increments 
(D9223), the surgical removal of erupted tooth (D7210), a problem focused extensive oral evaluation (D0160), 
a cone beam computed tomography (CT) scan (D0367), and a single administration of a therapeutic parenteral 
drug (D9610) provided on June 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you have enclosed confirmation that the oral 
surgeon was in-network, and the procedure was covered as unlimited. The Plan denied your request. The Plan 
says your benefit for general anesthesia for each subsequent 15 minute increments (D9223), and the surgical 
removal of erupted tooth (D7210) has already been exhausted. The Plan also says that a problem focused 
extensive oral evaluation (D0160), a cone beam computed tomography (CT) scan (D0367), and a single 
administration of a therapeutic parenteral drug (D9610) 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, certain limitations apply. The record 
shows your benefit for general anesthesia for each subsequent 15 minute increments (D9223), and the surgical 
removal of erupted tooth (D7210) was exhausted on date of service June 22, 2023. The record also shows that a 
problem focused extensive oral evaluation (D0160), a cone beam computed tomography (CT) scan (D0367), 
and a single administration of a therapeutic parenteral drug (D9610) are not covered under your benefit Plan. 
Therefore, we decided that the Plan does not have to pay for general anesthesia for each subsequent 15 minute 
increments (D9223), the surgical removal of erupted tooth (D7210), a problem focused extensive oral 
evaluation (D0160), a cone beam computed tomography (CT) scan (D0367), and a single administration of a 
therapeutic parenteral drug (D9610) provided on June 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital care for a partial removal of spine 
bone with release of upper spinal cord and/or nerves (63045, 63048) to be provided by an out-of-network 
(OON) provider/facility.  
 
You asked the Plan to pre-approve inpatient hospital care for surgery. You say that the requested services are 
medically necessary with an OON provider. The Plan denied your request. The Plan says there are providers 
that participate with your plan that can perform the surgery that you need for your neck. There are facilities that 
participate with your plan (in network), that are available and can provide the services that you require. 
 
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/facility in this case is not a network provider with the Plan. The Plan has network 
providers/facilities 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 inpatient hospital care for a partial removal of spine bone with release of upper spinal cord 
and/or nerves (63045, 63048) to be provided by an out-of-network (OON) provider/facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment the office visit, the injection, and the imaging 
provided on May 31, 2023. 
 
You asked the Plan to waive the copayment the office visit. You say that you have to get the procedure done 
every six weeks and $75 is too expensive. 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 $45 copayment for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or 
condition of the eye.  
 
You have been asked to pay a $45 copayment for the office visit. The office visit 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 the office visit, the injection, and the 
imaging provided on May 31, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve power elevating legrests (E1012), and electronic connection 
(E2311). 
 
You asked the Plan to pre-approve the power legrests and electronic connection. You say that the enrollee 
qualifies for and medically meets criteria for a Group 3 power wheelchair with tilt. You say that the enrollee is 
unable to perform independent, effective weight shift, and is at high risk for pressure ulcer. The Plan denied 
your request. The Plan says that the power leg lifts are not medically necessary. The Plan also says that the 
notes do not show there is a medical need to control the power options through the joystick. 
 
The Plan follows Medicare rules. Medicare rules say that a power seating component may be covered when the 
coverage 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 the power legrests and electronic 
connection. Our reviewer says that the requested power legrests and electronic connection are medically 
necessary. Our physician reviewer found the provided documentation indicates the enrollee is functionally non-
ambulatory and requires a power wheelchair for mobility and performing daily activities. They cannot perform 
pressure relief independently due to upper extremity weakness and require a power wheelchair with power tilt 
for adequate pressure relief and positioning. Power elevating leg rests are required for positioning of the lower 
extremities and lower extremity edema. The complexity of the enrollees seating and positioning needs 
necessitates a more complex Group 3 power wheelchair base. The electronic connection is necessary to operate the Group 3 power wheelchair base and the power options via a joystick. These components are required to 
operate the power options on a Group 3 power wheelchair base. The power elevating leg rests are medically 
necessary for positioning of the enrollees lower extremities and lower extremity edema. Therefore, the 
reviewer found that the requested electronic connection (E2311) and elevating leg rest (E1012) are 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 the power legrests and electronic connection have been met. Therefore, we 
decided that the Plan has to pre-approve power elevating legrests (E1012), and electronic connection (E2311).  
 
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: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. The Plan 
denied your request. The Plan says that although there are three requested power options (tilt, recline and 
elevating leg rests), there is not a medical need to control these power options through the joystick. 
 
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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are considered medically reasonable 
and necessary in this case. Our physician reviewer found the patient is non-ambulatory and requires a power 
wheelchair for mobility and performing daily activities. They cannot perform pressure relief independently 
require a power wheelchair with power tilt and recline for adequate pressure relief and positioning. The patient 
is noted to have a stage III pressure wound of the buttock. Power elevating leg rests are required for positioning 
of the lower extremities and lower extremity edema. Our reviewer found that the complexity of the patient's 
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. Our physician reviewer also found that 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 an electronic connection, harness, and expandable controller have been met. 
Therefore, we decided that the Plan has to pre-approve an 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.