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

 
We decided that the Plan does not have to pre-approve bilateral custom foot orthotics (L3010). 
 
You asked the Plan to pre-approve foot orthotics. You say that the items should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve bilateral 
custom foot orthotics (L3010).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 kyphoplasty (22514). 
 
You asked the Plan to pre-approve L1 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no documentation of progression of vertebral body height loss, greater than 
25% vertebral body height reduction, or kyphotic deformity. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific 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 L1 kyphoplasty. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the review of available imaging reports 
showed a depression of the superior endplate of L1 and focal increased uptake on bone scan. There is mention 
of computed tomography of the lumbar spine but no report. There is no mention of the degree of L1 
compression in the submitted records. Per LCD guidelines there must be at least 25% loss in height of the 
vertebral body in order to qualify for the procedure. Due to a lack of quantification of the degree of L1 
compression the medical necessity of the requested procedure is not established in the submitted records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L1 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L1 kyphoplasty (22514).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve several (7) additional health skilled nursing visits 
(G0299 x7). 
 
You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
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 the enrollee 
has stabilized following an episode of care. The enrollee does not have on-going instability or need for 
continued skilled observation.  
 
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 several (7) additional health skilled nursing visits (G0299 x7).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered pressure reducing air mattress (E0277).

You asked the Plan to pre-approve the mattress. You say that this will help prevent bed sores and other health issues. 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 the mattress. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has reduced bed mobility due to weakness from a spinal cord injury. The enrollee is noted to have a diabetic foot ulcer. There is no indication of a history of pressure wounds. The enrollee may require a hospital bed for re-positioning, but a pressure-reducing air mattress is indicated for patients with pressure wounds on the trunk or pelvis. Therefore, the powered pressure reducing air mattress (E0277) is not 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 mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered pressure reducing air mattress (E0277).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve two additional acupuncture visits.  
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that the requested services are not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan's rules apply in this case. 
 
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 two additional acupuncture visits. Our 
reviewer says that you meet criteria for coverage of the acupuncture services requested in this case. Our 
physician reviewer found that you have had acupuncture services for different pain complaints. Your complaint 
in this case is for new onset knee and arm pain. The request is for additional visits to address these areas. The 
requested acupuncture services 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve two additional acupuncture visits.   
 
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 pay for the hand finger orthosis (L3913-RT) provided on February 
24, 2023. 
 
You asked the Plan to pay for the orthosis. You say that you are requesting reconsideration for services 
advising review the attached medical records, the billed diagnosis codes are correct. The Plan denied your 
request. The Plan says M24.541 (Contracture, right hand) and M72.0 (Palmar fascial fibromatosis 
[Dupuytren]), should not be reported together which is based on the Excludes1 Notes instructions in the ICD-
10-CM Official Guidelines for Coding and Reporting. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 orthosis. Our reviewer found the medical records do not 
support the use of both diagnosis codes M24.541 and M72.0. Per coding guidelines, M24.541 has an Excludes1 
note for diagnosis code M72.0; therefore, M72.0 should not be billed. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the hand finger orthosis (L3913-RT) provided on February 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hyperbaric oxygen (HBO) under pressure, full body 
chamber, per 30-minute interval (G0277 x160 units) and the physician attendance and supervision of 
hyperbaric oxygen therapy, per session (99183 x40 units). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not 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 services. Our physician reviewer 
found the enrollee has stabilized following an episode of care. The enrollee does not have on-going instability 
or need for continued skilled observation.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the hyperbaric oxygen (HBO) under pressure, full body chamber, per 30-minute interval 
(G0277 x160 units) and the physician attendance and supervision of hyperbaric oxygen therapy, per session 
(99183 x40 units).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional home physical therapy visits.   

You asked the Plan to pre-approve the 12 additional home physical therapy visits. You say that the records 
provided support the need for the services in dispute.  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 the 12 additional home physical therapy 
visits. Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer 
found the enrollee is a 93-year-old female with history of right total hip arthroplasty on April 24, 2023. She had 
completed a course of physical therapy beginning May 15, 2023. The enrollee is a fall risk. The remaining 12 
sessions are not supported as 4 sessions should suffice to help reinstruct the enrollee on her home exercises and 
supervise for effectiveness and safety. The enrollee has showed ability to sit, transfer, walk, with minimal 
assistance. The records do not show skilled therapy services beyond the 4 additional approved sessions 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 according to the provided documentation.  
 
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 12 additional home physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 12 additional home physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939).  
 
You asked the Plan to pre-approve bone marrow aspirate. You say that this service is medically necessary. The 
Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature.  
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental when used as bone graft. Thus, this service is not considered 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve elbow support brackets for flip-back armrests (K0108 
x2), elbow support pads (K0108 x2), blue twister switch (K0108), and green twister switch (K0108). 
 
You asked the Plan to pre-approve elbow support brackets for flip-back armrests, elbow support pads, blue 
twister switch, and green twister switch. You say that based on the clinical level/evaluations, medical 
assessment, and the progressive nature of the enrollee's disease, a group 3 power wheelchair with power seat 
functions is recommended to meet the enrollee's mobility and medical needs over the next five years. The Plan 
denied your request. The Plan says the blue and green twister switches cannot be used for any part of the 
expandable controller and harness. The Plan says that the flip-back armrests are incorrectly coded. The Plan 
also says that armrests are already included with the approved E1007 power tilt and recline. 
 
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 elbow support brackets for flip-back 
armrests, elbow support pads, blue twister switch, and green twister switch. Our reviewer says that this request 
does not meet the criteria for coverage. Our physician reviewer found the expandable controller and harness 
includes switches. The flip away armrests and support brackets are included with the power tilt and recline. Our 
reviewer also found that the Plan is correct as the items are unbundled and incorrectly coded. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of elbow support brackets for flip-back armrests, elbow support pads, blue twister 
switch, and green twister switch have not been met. Therefore, we decided that the Plan does not have to pre-
approve elbow support brackets for flip-back armrests (K0108 x2), elbow support pads (K0108 x2), blue 
twister switch (K0108), and green twister switch (K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left atrial appendage closure (LAAC) with a Watchman 
device. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that LAAC is covered when specific 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has elevated risk of 
thromboembolic stroke due to atrial fibrillation and an elevated CHADS2VASC (congestive heart failure, 
hypertension, age 75 [doubled], diabetes, stroke [doubled], vascular disease, age 65 to 74 and sex category) 
score. There is no evidence that the enrollee is unable to tolerate anticoagulation, nor is there documentation of 
performance of an evidence-based shared decision-making interaction on anticoagulation. As such, guidelines 
would not support implantation of a LAAC in this setting. The services are therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve left atrial appendage closure (LAAC) with a Watchman device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E6075) provided on 
January 10, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says that the PCD is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a PCD coded as E0675 to treat PAD 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 pneumatic compression device have not been met. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (E6075) provided on January 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the crown and core buildup. You say that there were two fillings that fell out 
in the past year and you needed two crowns or a bridge. You also say that you have been paying for dental 
insurance for quite some time and never had a claim. The Plan denied your request. The Plan says there is no 
coverage for core buildup (D2950). 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the core buildup, including any pins 
when required is not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pre-approve the core buildup, including any pins when required (D2950).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76377 billed for February 7, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare will automatically deny claim line(s) items 
submitted with a GZ modifier. 
 
We looked at the file and Medicare rules. The claim at issue is denied by Medicare because it was billed with 
the -GZ modifier. Therefore, we decided that the Plan does not have to pay for procedure code 76377 billed for 
February 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller 
(E2377), and harness (E2313).  
 
You asked the Plan to pre-approve the electronic connection, expandable controller, and harness. You say that 
the records provided support the need for the items which remain in dispute.  The Plan denied your request. 
The Plan says the upgraded electronics are not medically necessary. The Plan also says the notes do not show a 
medical need to control the power options through the joystick.  
 
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 the electronic connection, expandable 
controller, and harness. Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has multiple sclerosis and relies on a 
wheelchair. The enrollee has strength 3-5/5 in upper extremities. The enrollee has adequate upper body strength 
to manage standard power drives. 
 
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, expandable controller, and harness have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), 
expandable controller (E2377), and harness (E2313).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the specialist office visits provided from 
March 9, 2022, to October 6, 2022. 
 
You asked the Plan to waive the copayments for the specialist office visits. You say that you have never had to 
pay for this service before. 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 $15 
copayment for each specialist office visit.  
 
You have been asked to pay a $15 copayment for each specialist office visit. This item/service falls within the 
physician/practitioner services 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 copayments for 
the specialist office visits provided from March 9, 2022, to October 6, 2022.