Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the criteria for eligibility have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, the record shows you do not meet all the required 
criteria. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the 
chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre 3 Sensor for the enrollee.
You asked the Plan to pre-approve a FreeStyle Libre 3 Sensor. You say that the services requested are
medically necessary. The Plan denied your request. The Plan says that this service is not a covered benefit.
Maximus overturned the Plan's denial. The Plan requested a reopening and stated that Maximus did not apply
the correct criteria.
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and
assigned code E2103 may be billed using this code.
We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM.
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does
not have to pre-approve a FreeStyle Libre 3 Sensor for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment billed for date of service 
February 10, 2023. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. 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 valid proof of delivery for the supplies provided in this case. 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 durable medical equipment billed for date of service February 10, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 98942 and 97124 billed for date of services
May 25, 2022, to July 6, 2022.
You asked the Plan to pay for procedure codes 98942 and 97124. You say that the claim should be paid as
billed. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value cannot be paid when the MAI value is 2. Medicare rules say that providers must report
services correctly. Providers must report services with the appropriate CPT code.
In this case, the MUE for CPT code 98942 is 1. The MAI value for this code is 2. You billed 2 units of this
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of
procedure code 98942 have not been met. In this case, we have confirmed that code 97124 is a column II code
to column I code 97140 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 codes 98942 and 97124 billed for date of services May 25, 2022, to July 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210) provided on February 14, 2023. 
 
You asked the Plan to pay for an extraction. You say that this should be covered. The Plan denied your request. 
The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
extraction (D7210) provided on February 14, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for durable medical equipment code A4239 billed for date of service 
March 17, 2023. 
 
You asked the Plan to pay for the billed services. You say that this is a valid code. The Plan denied your 
request. The Plan says that the code is always bundled into payment for other services. 
 
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 find that CPT code A4239 is payable under the durable medical equipment fee schedule. The provider is 
not a physician. The claim and national provider identifier (NPI) information does not indicate the services 
should be processed under the physician fee schedule. Based on this information, we decided that Medicare 
rules for coverage of the billed services have been met. Therefore, we decided that the Plan has to pay for 
durable medical equipment code A4239 billed for date of service March 17, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder monitor test (0013M) provided on November 
14, 2022. 
 
You asked the Plan to pay for the Cxbladder monitor test. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder monitor test (0013M) have not been met. Therefore, 
we decided that the Plan does not have to pay for the Cxbladder monitor test (0013M) provided on November 
14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on January 25, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on January 25, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a flex-walk system (L5981) and multiaxial ankle with swing phase 
active dorsiflexion feature (L5968).  
 
You asked the Plan to pre-approve the prosthesis components. You say that you have increased to a K3 
ambulator. You also say that you have met the Medicare requirements for an advanced foot and ankle feature. 
The Plan denied your request. The Plan says that the records to not support that you are a K3 ambulator. 
 
The Plan follows Medicare rules. Medicare rules say that prosthetic components may be covered when certain 
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 prosthesis components. Our 
reviewer says that the requested components are medically necessary. Our physician reviewer found the 
provided documentation very thoroughly and explicitly document your K3 status now and in the near future 
with the provision of the foot in question, and your overall medical condition appears stable and well managed. 
The reviewer found that use of an assistive device, such as a cane or even a rolling walker is not necessarily a 
factor in determining K-level. Therefore, the reviewer found that the requested components are 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 the prosthesis components have been met. Therefore, we decided that the Plan 
has to pre-approve a flex-walk system (L5981) and multiaxial ankle with swing phase active dorsiflexion 
feature (L5968).   
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88342 billed for date of service December 
13, 2022.  
 
You asked the Plan to pay for procedure code 88342. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88342 is 4. The MAI value for this code is 3. You billed 6 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88342 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88342 billed for date of service December 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services coded G0483 provided on July 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services coded G0483 provided on July 5, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve pontics (D6240 and a retainer crown (D6750) for tooth #8, #9, 
#10, and #11. 
 
You asked the Plan to pre-approve the dental services. You say that you need the dental procedures completed 
and they cannot be individually done. The Plan denied your request. The Plan says that the benefit limit has 
been exhausted for the requested dental services. 
 
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. There was no documentation received specifically the Evidence of Coverage to 
show the limitation on the requested documentation; therefore, the Plan did not support their reason for denying 
the dental services for the benefit level being exhausted. Therefore, we decided that the Plan has to pre-approve 
pontics (D6240 and a retainer crown (D6750) for tooth #8, #9, #10, and #11.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service July 18, 
2022.  
 You asked the Plan to pay for procedure code 0003A. You say that this is a coverable service and this claim 
should be paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service July 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch and cane holder (E2207) for a wheelchair. 
 
You asked the Plan to pre-approve a crutch and cane holder. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested item does not serve a 
primarily medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a crutch and cane holder (E2207) for a wheelchair.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that 
there is low suspicion fainting episodes are caused by a heart problem.  
 
The Plan follows Medicare rules. Medicare rules say that electrocardiographic services are only covered under 
certain medical indications. 
 
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 requested services. Our physician 
reviewer found that the enrollee has chronic atrial fibrilation, brady-tachy-arrhythmia, and recurrent syncope. 
Due to infrequent syncope of uncertain etiology, and inconclusive adequately long external monitoring, the 
enrollee will benefit from the ILR implantation, making decision about the possibility of need for a pacemaker. 
Therefore, the request is 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 the requested services have been met. Therefore, we decided that the Plan has to 
pre-approve an implantable loop recorder.  
 
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 pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that these benefits should be approved. The Plan 
denied your request. The Plan says the criteria for eligibility have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81479 for date of service 
August 26, 2021. 
 
You asked the Plan to pay for the laboratory services coded 81479. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
coded 81479 have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
services coded 81479 for date of service August 26, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the hospital services received from December 29, 2022, 
to January 1, 2023 minus any cost share requirement. 
 
You asked the Plan to pay for the hospital services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that the claim requires a corrected claim. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the hospital services by a contract provider. The file does not show that the Plan provided 
notice that the hospital services would not be covered. Under Medicare rules, this means the hospital services is 
considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the hospital 
services received from December 29, 2022, to January 1, 2023 minus any cost share requirement.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on March 5, 2022. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that the submitted 
documents support the request for the services rendered The Plan denied your request. The Plan says our policy 
covers non-emergency ambulance transportation when it is the only way to transport a member safely and 
adequately or if other means of transporting a member are unsafe due to a medical condition. This claim does 
not meet these requirements. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 pay for the ambulance service and ground mileage. 
Our reviewer says that the ambulance services was not medically necessary.  Our physician reviewer found the transportation via ambulance from the hospital to home upon discharge was 
not medically necessary. The enrollee did not require the expertise of trained personnel or the equipment 
available only on an ambulance in order to effectuate a safe transport.  Transportation could have been 
provided by other means (stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's 
condition. 
 
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 ambulance service and ground mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, 
and ground mileage provided on March 5, 2022.