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

 
We decided that the Plan does not have to waive the copayments for the bone morrow biopsy and ambulance 
service provided from May 25, 20223, to May 30, 2023. 
 
You asked the Plan to waive the copayments for the bone morrow biopsy and ambulance service. You say that 
you had met your maximum out-of-pocket amount. 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 $350 
copayment for in-network outpatient surgery. Your contract with the Plan clearly says that you must pay a 
$275 copayment for out-of-network ground ambulance services.  
 
The records show your maximum out-of-pocket amount was processed correctly. You have been asked to pay a 
$350 copayment for the bone morrow biopsy. This item/service falls within the outpatient surgery benefit 
category. You have also been asked to pay a $275 copayment for the ambulance services. This item/service 
falls within the ambulance 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 bone morrow biopsy and ambulance service provided from May 25, 20223, to May 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.

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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have difficulty walking more than 50 feet due to low back and knee pain. There is a lack of clinical documentation indicating your level of function and physical examination findings, specifically with regard to your motor strength in the arms and legs. There is also a lack of information regarding whether you can operate the requested power scooter and if your home is accessible for it. The criteria for coverage are not met and the power scooter is not reasonable or medically necessary at this time.

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 a power scooter.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the thyroid testing (84443) provided on June 7, 2023. 
 
You asked the Plan to pay for the thyroid testing (84443). You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that lab services ordered for screening 
purposes are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that thyroid testing billed with code 84443 is 
coverable when billed with diagnosis codes R25.2, R60.0, E11.9, and Z79.899. The claim in this case was 
billed with diagnosis code E11.9. There is no evidence that this testing was ordered just for screening purposes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 84443 have been met. Therefore, we decided that the Plan has to pay for the thyroid testing 
(84443) provided on June 7, 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 procedure code 87798 provided on January 23, 2023. 
 
You asked the Plan to pay for procedure code 87798. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 
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 87798 is Infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism. 
 
We find that CPT code 87798 is not supported in the medical record. Specifically, this code is a not otherwise 
specified code, and the documentation does not contain a complete description of the not otherwise specified 
code. Based on this information, we decided that Medicare rules for coverage of procedure code 87798 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87798 provided on 
January 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical traction device (E0849). 
 
You asked the Plan to pay for the cervical traction device. You say that the item should be covered. The Plan 
denied your request. The Plan says the diagnosis on the records doesn't match the diagnosis on the prescription 
 
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, or relevant medical records which support medical 
necessity for the supplies provided in this case. There is no indication in the medical records this device was ordered or needed and the diagnosis on the prescription does not match any in the medical records. 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 cervical traction device (E0849).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-pneumatic compression controller with sequential 
calibrated gradient pressure (K1024) and a non-pneumatic sequential compression garment, half leg (K1033). 
 
You asked the Plan to pre-approve a Koya Dayspring device. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the clinical value and effectiveness of a Koya Dayspring non-
pneumatic compression system, in the setting of lymphedema 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 a Koya Dayspring device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found provided medical records and review of the current peer-reviewed medical literature 
do not document that use of the Koya Dayspring Device has been shown in controlled studies in a Centers for 
Medicare and Medicaid Services (CMS)-approved journal to result in long term health benefits in enrollees 
with lymphedema or improved outcomes compared to the standard pneumatic devices. Despite a prescription 
stating that the enrollee has tried and failed pneumatic devices, the medical records only report trial and failure 
of leg elevation, physical therapy, and compression stockings. 
 
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 Koya Dayspring device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a non-pneumatic compression controller with sequential calibrated gradient 
pressure (K1024) and a non-pneumatic sequential compression garment, half leg (K1033).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power mobility device (K0899). 
 
You asked the Plan to pre-approve a power mobility device. You say that you cannot get around at all without 
the scooter. The Plan denied your request. The Plan says based on Medicare guidelines, the K0899 power 
mobility device requested does not meet the requirements for approval.  
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment. 
Medicare rules also say that all DMEPOS items require a written order/prescription from the treating 
practitioner for Medicare payment as a condition of payment. 
 
We looked at the file and Medicare rules. Specifically, the provided records do not show that you have had a 
home assessment, showing that there is enough room in your home to use the requested device. Based on this 
information, we decided that the Medicare rules for coverage of the power mobility device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a power mobility device (K0899).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve a bone marrow aspirate. You say that this 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 a 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 remains experimental in spine surgery. More research is 
needed. 
 
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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone marrow aspirate (20939).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray, bitewing x-ray, and core buildup services 
(D0220, D2950, D0270) provided on June 5, 2023, to July 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 22, 2022 (D0220) 
and February 8, 2023 (D0270). Therefore, we decided that the Plan does not have to pay for an intraoral x-ray, 
bitewing x-ray, and core buildup services (D0220, D2950, D0270) provided on June 5, 2023, to July 24, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vraylar. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vraylar.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair with a patient 
weight capacity 301 to 450 pounds (K0837) and additional items and accessories (codes E0955, E1002, E1028, 
E2361, and E2604). 
 
  You asked the Plan to pre-approve a group 2 heavy duty power wheelchair and additional items and 
accessories. You say that the enrollee meets all the requirements including their weight for the requested power 
wheelchair. The Plan denied your request. The Plan says the enrollee's weight does not meet the Medicare 
weight criteria for a K0837 power wheelchair. The Plan also says that as the power wheelchair is not Medicare-
covered, the added features would not be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a PWC is covered if the beneficiarys weight is 
less than or equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 
95% of the weight capacity of the next lower weight class PWC. Medicare rules also say if the base PWC is not 
covered, then related accessories will be denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a group 2 heavy duty power wheelchair and additional items and accessories have not been met. 
Specifically, the provided records show that the enrollee's most recent documented weight is below the 
required weight limit of 301 to 450 pounds for a group 2 heavy duty power wheelchair (K0837). Therefore, we 
decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair with a patient 
weight capacity 301 to 450 pounds (K0837) and additional items and accessories (codes E0955, E1002, E1028, 
E2361, and E2604).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical traction device (E0849). 
 
You asked the Plan to pay for the cervical traction device. You say that the item was medically necessary. The 
Plan denied your request. The Plan says the diagnosis on the records doesnt match the diagnosis on the 
prescription. 
 
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 or relevant medical records which support medical 
necessity for the supplies provided in this case. The medical records do not indicate a covered diagnosis for this 
device. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the cervical traction device have not been met. Therefore, we decided that the Plan does not have 
to pay for the cervical traction device (E0849).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87498, 87502, 87634, 87798, U0003, and 
U0005) provided on February 9, 2023. 
 
You asked the Plan to pay for procedure codes 87498, 87502, 87634, 87798, U0003, and U0005. You say that 
you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the panel testing have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the panel testing (87498, 87502, 87634, 87798, U0003, and U0005) provided on February 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 15, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sixty (63) additional alginate or other fiber gelling 
dressing, wound covers (A6197), thirty (30) additional gauze, impregnated with other than water, normal 
saline, or hydrogel pads (A6223) and twenty (20) additional gauze, non-impregnated, sterile, pad (A6402). 
 
You asked the Plan to pre-approve additional wound care dressing supplies. You say that you only get 10 days 
of wound care supplies with what the Plan has approved. You need additional supplies. The Plan denied your 
request. The Plan says you have been approved for the maximum benefit of wound care supplies per month. 
You do not have a current wound evaluation or note why the extra bandages are needed. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of additional wound care dressing supplies have not been met. Specifically, the Plan says no more 
than a months supply of dressings may be provided at one time, unless there is documentation to support the 
necessity of greater quantities in the home setting in an individual case. The records do not show 
documentation to support why additional bandages are necessary. Therefore, we decided that the Plan does not 
have to pre-approve sixty (63) additional alginate or other fiber gelling dressing, wound covers (A6197), thirty 
(30) additional gauze, impregnated with other than water, normal saline, or hydrogel pads (A6223) and twenty 
(20) additional gauze, non-impregnated, sterile, pad (A6402).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 billed for date of service November 
17, 2022. 
 
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 does not support the 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. 
 
In this case, the CPT Code Manual definition of code 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique.  
 
We find that 5 units of CPT code 87481 is not supported in the medical record. Specifically, the records only 
support 4 units were provided. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
87481 billed for date of service November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on June 29, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the nursing facility care. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service was not authorized. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for the nursing facility care provided on June 29, 2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on June 21, 2023. 
 
You asked the Plan to pay for the hearing aids. You say that you were told you had a $1,000 benefit and that 
you could receive hearing aids from several providers. You say that you assumed you could get your hearing 
aids through your in-network audiologist. The Plan denied your request. The Plan says the hearing aids were 
purchased out-of-network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids when they are received by network vendors.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Specifically, the provider is not a part of the Plan's hearing 
vendor network Therefore, we decided that the Plan does not have to pay for the hearing aids provided on June 
21, 2023.