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

 
We decided that the Plan does not have to pay for the hip orthosis (L1686, L2624) provided on April 11, 2023. 
 
You asked the Plan to pay for the hip orthosis. You say that the items are medically necessary. 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.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. There is nothing in the medical records submitted indicating these items were needed or ordered. The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the hip orthosis (L1686, L2624) provided on April 
11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compressor and segmental gradient pressure 
pneumatic appliance to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve pneumatic compressor and segmental gradient pressure pneumatic 
appliance. You say that the supplies should be covered. The Plan denied your request. The Plan says this is 
available in-network. 
 
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 
pneumatic compressor and segmental gradient pressure pneumatic appliance to be provided by an out-of-
network (OON) provider.
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  
6-1000051849 
  
 
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 pre-approve genicular nerve radiofrequency ablation. 
 
You asked the Plan to pre-approve genicular nerve radiofrequency ablation. You say that the enrollee has 
severe right knee pain. She has done well with the procedure on her left knee and would like the same on her 
right knee. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve genicular nerve radiofrequency 
ablation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found this procedure is considered experimental/ investigational 
at this time.  It is the subject of ongoing clinical trials.  Therefore, the request is deemed not medically 
reasonable and 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 genicular nerve radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for take-home supply of methadone and medication assisted 
treatment provided on April 17, 2023. 
 
You asked the Plan to pay for take-home supply of methadone and medication assisted treatment. You say that 
this service is supported in the records. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for take-home supply of 
methadone and medication assisted treatment provided on April 17, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health physical therapy visits. 
 You asked the Plan to pre-approve home health services. You say that you need more physical therapy and 
cannot walk with the range motion that you have. The Plan denied your request. The Plan says the services are 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
clinical documentation shows that the enrollee has medical history of right total knee arthroplasty and 
requested home health physical therapy for chronic back pain. However, a televisit documentation does not 
specify that the enrollee is home bound or show that it was ordered in assessment/plan. The records do not 
show that skilled physical therapy services in the home setting are required to effectively provide treatment, 
care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance 
program to maintain the enrollee's level of function and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 24, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says the services were not authorized. 
 
 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 the office visit provided on May 24, 2023, by an 
OON provider.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99204-25 rendered on October 24, 2022. 
 
You asked the Plan to pay for the services. You say that the claim was denied in error. The Plan denied your 
request. The Plan says that the denial of CPT 99204-25 is appropriate. 
 
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. CPT 99204 was billed with modifier -25, which is used to describe a significant 
and separately identifiable evaluation and management service. This could be a valid modifier to use in this 
case if there is documentation to support the modifier. The plan did not provide medical records to verify their 
denial of this code and the modifier. There is no evidence that they requested any medical records. Therefore, 
we decided that the Plan has to pay for procedure code 99204-25 rendered on October 24, 2022.  
 
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 waive the copayment for prosthetic devices provided on February 
23, 2023. 
 
You asked the Plan to waive the copayment for prosthetic devices. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for prosthetic devices. 
 
You have been asked to pay a $30 copayment for prosthetic devices. This item/service falls within the 
prosthetic devices 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 are being asked to pay is $210 ($30 x 7 = $210). Therefore, we decided that 
the Plan does not have to waive the copayment for prosthetic devices provided on February 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0823), and battery (E2361). 
 
You asked the Plan to pre-approve a power wheelchair and battery. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair and battery. Our 
reviewer says that the items are not medically necessary. Our physician reviewer found that you have sufficient 
capacity to complete MRADLs in the home with a lightweight 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 a power wheelchair and battery have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a power wheelchair (K0823), and battery (E2361).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 27, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services should be covered. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on March 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for X-ray services provided on April 27, 2023. 
 
You asked the Plan to pay for X-ray services. You say that the services should be covered. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for X-ray services provided 
on April 27, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93970 for date of service August 29, 2022. 
 
You asked the Plan to pay for procedure code 93970. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that code 93970 is covered when billed with specific 
diagnosis codes. Any diagnosis code not listed is not covered. 
 
We looked at the file and Medicare rules. Review of the file shows that this service was billed with diagnosis 
codes M17.0 (bilateral primary osteoarthritis of knee) and M25.561 (pain in right knee). These diagnosis codes 
are not listed as covered diagnosis codes for this procedure. This means code 93970 is not payable as billed. 
Based on this information, we decided that Medicare rules for coverage of procedure code 93970 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 93970 for date of service 
August 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you would like a battery-
operated tank so you can go out and about with your family. The Plan denied your request. The Plan says you 
will not be eligible to start a new rental period until December 8, 2025. 
 
The Plan must follow Medicare rules. The rules say Medicare reimbursement for oxygen equipment is limited 
to 36 monthly rental payments. Payment for accessories (e.g., cannula, tubing, etc.), delivery, back-up 
equipment, maintenance, and repairs is included in the rental allowance. 
 
The file shows that you started a new capped rental period on December 8, 2020, and will not be eligible to 
start a new capped rental period until December 8, 2025. You currently have portable tanks to meet your 
oxygen needs and there is no evidence that they are broken beyond repair. Therefore, we decided that the Plan 
does not have to pre-approve a portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network outpatient diagnostic tests 
provided on January 03, 2023. 
 
You asked the Plan to waive the copayment for out-of-network outpatient diagnostic tests. You say that you 
disagree with the copayment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for out-of-network outpatient diagnostic tests/X-rays. 
 
You have been asked to pay a $20 copayment for out-of-network outpatient diagnostic tests. This item/service 
falls within the out-of-network outpatient diagnostic tests/X-rays 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 are being asked to pay $40 
($20 x 2 X-rays = $40) Therefore, we decided that the Plan does not have to waive the copayment for out-of-
network outpatient diagnostic tests provided on January 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endoscopy provided on January 05, 2023. 
 
You asked the Plan to pay for an endoscopy. You say that this is medically necessary, and you have a referral 
from the provider. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an endoscopy provided 
on January 05, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Synvisc or Synvisc-One injection (J7325), arthrocentesis 
(20610), fluoroscopic guidance (77002), and octafluoropropane microspheres injections (Q9956 x 2) provided 
on March 9, 2023, by an out-of-network provider. 
 
You asked the Plan to pay for the outpatient services. You say that this was approved. The Plan denied your 
request. The Plan says there was no information provided to support why these services should be covered. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the outpatient services have been met. 
Specifically, there were no medical records provided to support that the services at issue were medically 
necessary. The record shows that the Plan requested this information, but nothing was received. Therefore, we 
decided that the Plan does not have to pay for the Synvisc or Synvisc-One injection (J7325), arthrocentesis 
(20610), fluoroscopic guidance (77002), and octafluoropropane microspheres injections (Q9956 x 2) provided 
on March 9, 2023, by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Chemotherapy administration (96402, 36415, J9217, J0897, 
96372) provided on March 29, 2023. 
 
You asked the Plan to pay for Chemotherapy administration (96402, 36415, J9217, J0897, 96372). You say 
that the service can be provided by an in-network provider. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for Chemotherapy 
administration (96402, 36415, J9217, J0897, 96372) provided on March 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a manuel wheelchair base provided on February 23, 2023. 
 
You asked the Plan to pay for a manuel wheelchair base. You say that this was medically necessary and should 
be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a manuel wheelchair 
base provided on February 23, 2023.