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

 
We decided that the Plan does not have to pay for lab services (87086) provided on February 15, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the code was not billed with a valid primary diagnosis code. 
 
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 87086 is Culture, bacterial; quantitative colony count, 
urine. 
 
We find that CPT code 87086 is not supported in the medical record. Specifically C61 is not a valid primary 
diagnosis code for this test, per National Coverage Determination: Urine Culture (190.12). Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (87086) provided on February 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics, foot insert.  
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because the 
requested foot orthotics are medically necessary. 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 you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics, foot insert.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hi-index lens enhancement provided on February 7, 2023. 
 
You asked the Plan to pay for hi-index lens enhancement . You say that the lenses are medically necessary for 
normal daily functioning. The Plan denied your request. The Plan says the service 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 basic single vision, lined bifocal, lined trifocal, and lenticular lenses only. 
 
We looked at the file and the Plan's rules. Specifically, the hi-index lens is considered an enhancement which is 
not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of hi-index lens 
enhancement have not been met. Therefore, we decided that the Plan does not have to pay for the hi-index lens 
enhancement provided on February 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump. 
 
You asked the Plan to pre-approve these services. You say that the enrollee needs the cold pad after surgery. 
The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a fluid circulating cold pad with pump (E0218) will be 
denied as not reasonable and necessary. 
 
The item at issue is a fluid circulating cold pad with pump described by code E0218. This item is denied by 
Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pre-approve a fluid 
circulating cold pad with pump.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gradient compression wrap provided on November 25, 
2022. 
 
You asked the Plan to pay for the gradient compression wrap. You say that you disagree with the Plan's denial. 
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 a valid physician order for the supplies provided in this case. Review of the file 
shows that the provider did not provide a Standard Written Order to support the ordering of the supplies 
rendered. 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 gradient compression wrap provided 
on November 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hip joint replacement surgery (27130) to be provided by 
an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve hip joint replacement surgery to be provided by an OON provider. You say 
that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that 
are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
hip joint replacement surgery (27130) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the durable medical equipment provided on February 3, 2023. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does contain a valid physician order and proof of delivery. Review of the file does not reveal any 
reason that the required documentation is invalid. The delivery ticket includes the tracking number, which links 
the delivery ticket to the proof of delivery with the same tracking number. Additionally, the provider used the 
shipping date as the date of service correctly. Therefore, we decided that the Plan has to pay for the durable 
medical equipment provided on February 3, 2023.  
 
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 refraction provided on January 24, 2023. 
 You asked the Plan to pay for the refraction. You say that you needed the exam to get your right cataract 
removed. The Plan denied your request. The Plan says the service 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 eye refractions during a routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was not provided during a routine eye 
examination. The medical records show diagnoses for cataracts and vision loss which makes the eye exam 
medical in nature. Based on this information, we decided that the Plan's rules for coverage of the refraction 
have not been met. Therefore, we decided that the Plan does not have to pay for the refraction provided on 
January 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71100 billed for date of service October 1, 
2022.  
 
You asked the Plan to pay for procedure code 71100. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 71100 is bundled into payment for code 
71101. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71100 
is a column II code to column I code 71101 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 71100 billed for date of service October 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ablation, malignant breast tumor(s), percutaneous, 
cryotherapy, including imaging guidance when performed, unilateral (0581T). 
 
You asked the Plan to pre-approve breast cryosurgery. You say that this surgery has been performed for 20 
years and is not experimental.  The Plan denied your request. The Plan says coverage cannot be approved for 
this service because there is not enough medical proof that shows the safety and/or success of this procedure. 
Right now, this type of surgery is considered experimental and/or unproven.  
 
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 breast cryosurgery. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that cryoablation is not considered a standard of care. Use is not supported by the medical literature or the National Comprehensive Cancer Network (NCCN) Guidelines. The service is not 
reasonable or 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 breast cryosurgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ablation, malignant breast tumor(s), percutaneous, cryotherapy, including imaging 
guidance when performed, unilateral (0581T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre Kit 3 Sensor.  
You asked the Plan to pre-approve Freestyle Libre Kit 3 Sensor. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 Freestyle Libre Kit 3 Sensor. Our 
reviewer says that the documentation does not support that the requested device is medically reasonable or 
necessary. Our physician reviewer found the documentation does not support that the enrollee has low blood 
sugar levels. The documentation does not support that the enrollee uses insulin. Therefore, the enrollee does not 
meet criteria for the requested device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Freestyle Libre Kit 3 Sensor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Freestyle Libre Kit 3 Sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. The Plan denied your request. The Plan says the requested services can be rendered by equally 
qualified in-network providers that are available for the member. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 pressure-reducing mattress. 
 
You asked the Plan to pre-approve the Group 2 mattress. You say that the enrollee has a past medical history of 
receiving a flap due to skin complication and will need a pressure relief mattress. The Plan denied your request. 
The Plan says the criteria for the requested support surface are not met.  
The Plan follows Medicare rules. Medicare rules say that a Group 2 pressure-reducing support surface may be 
covered for enrollees without active pressure ulcers only when there has been a skin flap procedure performed 
within the past 60 days. 
 
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 Group 2 mattress. Our reviewer 
says that the criteria for the requested Group 2 support surface are not met.  Our physician reviewer found the 
enrollee has quadriplegia and a history of skin flaps; however, there have been no skin flap procedures within 
the last 60 days, and there are no current skin issues.  
 
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 Group 2 mattress have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Group 2 pressure-reducing mattress.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  a pneumatic compression device (E0675) provided 
December 5, 2022, to December 29, 2022. 
 
You asked the Plan to pay for  a pneumatic compression device. You say that the use of the unit helped reduce 
post-surgical complications and t need for pain medications while improving the enrollee's range of motion. 
The Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to 
prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for  a pneumatic compression device (E0675) provided December 5, 2022, to December 29, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an insulin pump 
 
You asked the Plan to pre-approve the insulin pump. You say that the new Tandem T-slim 2 insulin pump is 
medically necessary to continue management of the enrollee's diabetes mellitus with their Dexcom continuous 
glucose monitor.  The Plan denied your request. The Plan says that the clinical documentation received is not 
evident of meeting the required criteria mentioned in the Medicare guidelines. 
 
The Plan follows Medicare rules. Medicare rules say that insulin pumps may be covered for enrollees who 
meet coverage indications within certain categories. 
 
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 insulin pump. Our reviewer says 
that the insulin pump is medically necessary. Our physician reviewer found the enrollee has a low or actually 
undetectable C-peptide level hence confirming criterion, A. the pump is justified and medically necessary and 
indicated for them. 
 
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 insulin pump have been met. Therefore, we decided that the Plan has to pre-
approve an insulin pump  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an Intrauterine Device (IUD) with levonorgestrel 52mg. 
 
You asked the Plan to pay for the IUD. You say that this device is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing 
conception (contraception) are not considered medically reasonable and necessary.  
 
Records show that the requested service is primarily for the purpose of contraception. The documentation does 
not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for 
coverage of this item/service have not been met. Therefore, we decided that the Plan does not have to pay for 
an Intrauterine Device (IUD) with levonorgestrel 52mg.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision supply provided on November 14, 2022. 
  
You asked the Plan to pay for the vision supply. You say that you are being told that the two dates that you 
received eyewear are too close together. You say that is incorrect. The Plan denied your request. The Plan says 
the benefit has been exhausted. 
 
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 one pair of eyewear every 24 months. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid for eyewear received on May 27, 2021, 
which exhausted the benefit. The record shows the vision item provided on November 14, 2022, is within the 
24-month limitation. Based on this information, we decided that the Plan's rules for coverage of the vision 
supply have not been met. Therefore, we decided that the Plan does not have to pay for the vision supply 
provided on November 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  a pneumatic compression device (E0675) November 14, 
2022, to December 4, 2022. 
 
You asked the Plan to pay for  a pneumatic compression device. You say that you are requesting 
reconsideration based on medical necessity for this enrollee and evidence based medical literature that 
substantiate the efficacy of the treatment rendered. The Plan denied your request. The Plan says pneumatic 
compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following 
surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for  a pneumatic compression device (E0675) November 14, 2022, to December 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CTA scan of the chest. 
 
You asked the Plan to pay for a CTA scan of the chest. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says no information was 
received to determine the medical necessity.  
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 a CTA scan of the chest have been met 
due to missing medical records. Therefore, we decided that the Plan does not have to pay for a CTA scan of the 
chest.