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

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that the requested power scooter is needed for 
inside and outside use. The Plan denied your request. The Plan says that the requested scooter is intended for 
outside use. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a power scooter. Our reviewer says that 
the coverage criteria has not been met. Our physician reviewer found that the clinical documentation indicates 
that you have no significant neurological or musculoskeletal deficits. You are independent with mobility and 
performing your activities of daily living. The records show you would only use the power scooter for mobility 
in the community for long distances. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a network exception for a nonpowered advanced 
pressure reducing overlay for mattress (E0371) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a network exception for the pressure reducing overlay. You say that an in-
network exception should be made. You also say that the requested item is medically necessary. The Plan 
denied your request. The Plan says the requested item can be provided by a network provider. 
 
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 a network exception for 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 item at issue in this appeal. We found no exception that would require the Plan 
to pre-approve a network exception for these items. Therefore, we decided that the Plan does not have to pre-approve a network exception for a nonpowered advanced pressure reducing overlay for mattress (E0371) to be 
provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories. 
 You asked the Plan to pre-approve a power wheelchair and accessories. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices are 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 a power wheelchair and accessories. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the record does 
not support the enrollee's needs can not be met with a manual wheelchair. He has normal neurological function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for physician's services for an emergency department visit provided on 
September 23, 2022. 
 
You asked the Plan to pay for the physician's services for an emergency department visit. You say that you 
have provided proof of enrollment from CMS for this provider. The Plan denied your request. The Plan says 
that this provider has been precluded from participation in Medicare at the time services were rendered. 
 
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. Specifically, the Plan has not provided documentation showing that this 
physician (NPI 1285083519) and/or the billing group (NPI 1861430555) have been precluded from 
participation in Medicare at the time services were rendered. Therefore, we decided that the Plan has to pay for 
physician's services for an emergency department visit provided on September 23, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 78452 billed for date of service December 17, 2022. 
 
You asked the Plan to pay for procedure code 78452. You say that this service was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says that this service was not billed 
with a diagnosis which supports the medical necessity of this service. Therefore, this service is denied based on 
a coding error per Medicare Local Coverage Article: Billing and Coding: Cardiovascular Nuclear Medicine 
(A56743). 
 
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. Specifically, while the article cited by the Plan does apply to the services at 
issue, the article clearly states that diagnosis codes which do not support medical necessity of any procedure 
codes in any group in the article do not apply. This means that although there is a list of procedure codes which 
would likely support medical necessity of these services, the use of a code which is not on this list is not 
automatically excluded as not medically necessary. The Plans denial of this service based solely on coding is 
not appropriate or supported in this case. Therefore, we decided that the Plan has to pay for procedure code 
78452 billed for date of service December 17, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the seat lift with chair provided on August 16, 
2022. 
 
You asked the Plan to reimburse you for the seat lift with chair. You say that the enrollee's provider advised the 
enrollee needed a lift chair to help the enrollee get up. You also say that this was paid out-of-pocket. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to reimburse you for the seat lift with chair provided on August 16, 
2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve all white glass crown (D2740) for teeth #9 and #10. 
 
You asked the Plan to pre-approve crowns for teeth #9, #10. You say that this is medically necessary. The Plan 
denied your request. The Plan says that this is not medically necessary. 
 
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. The Plan has not sent the required x-rays to determine medical necessity. 
Therefore, we decided that the Plan has to pre-approve all white glass crown (D2740) for teeth #9 and #10.  
 
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 genetic testing provided on November 28, 2022, billed 
with codes 81225, 81226, 81227, 81231, 81240, 81241, 81291, 81328, 81335, 81479 and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 28, 2022, billed with codes 81225, 81226, 81227, 81231, 81240, 81241, 81291, 81328, 81335, 
81479 and 81238.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excess skin removal (panniculectomy). 
 
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 a panniculectomy 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 records show that you have excess 
skin resulting in a large pannus. You are attempting to lose weight and the records do not document a stable weight for six months. There is no documentation of chronic rash (intertrigo) that has not responded to medical 
therapy or inability to perform activities of daily living. The criteria for coverage are not met and the services 
are 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 excess skin removal (panniculectomy).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G device. 
 
You asked the Plan to pre-approve the MyoPro device. You say that he requested device is medically 
necessary. The Plan denied your request. The Plan says that the MyoPro device 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 MyoPro device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that current clinical guidelines for adult stroke rehabilitation and recovery designate 
robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise 
therapies" with unproven benefit in the home environment. 
 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 MyoPro device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro Motion G device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and to waive the copayment for cardiology 
testing and to pay for injections provided on December 13, 2022, to December 14, 2022. 
 
You asked the Plan to waive the copayment and to pay for cardiology testing and injections. You say that you 
believe the Plan shou pay for this. 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 $25 
copayment for outpatient diagnostic tests/diagnostic procedures and tests/outpatient hospital.  
 
You have been asked to pay a $25 copayment for cardiology testing. This item/service falls within the 
outpatient diagnostic tests/diagnostic procedures and tests/outpatient hospital benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. The total amount you owe 
for self-administered drugs is $207.65 due to not being covered. The total amount you are being asked to pay is 
$232.65 ($25 copayment + $207.65 non-covered benefits = $232.65). 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 copayment for cardiology testing and to pay for injections provided on December 13, 2022, to 
December 14, 2022.  
 
Your complaint about being mistreated is not a valid appeal for medical coverage. This part of your complaint 
is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these 
types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental services on January 27, 2022, to July 28, 
2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like to request reconsideration 
for payment. The Plan denied your request. The Plan says you are responsible for any charged amount above 
the Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the dental services on January 27, 2022, to 
July 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve selective catheter placement, arterial system; initial third 
order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family. 
 
You asked the Plan to pre-approve selective catheter placement, arterial system. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 selective catheter placement, arterial 
system. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is insufficient evidence in the medical literature to 
support the use of selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family for the treatment of synovitis and 
tenosynovitis, unspecified, and pain in the right knee secondary to osteoarthritis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of selective catheter placement, arterial system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve selective catheter placement, arterial system; initial third 
order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 8, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Iovera. 
 
You asked the Plan to pre-approve Iovera. You say that you have severe shoulder pain. The Plan denied your 
request. The Plan says Iovera is considered experimental and investigation and is not covered by Medicare. 
 
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 Iovera. Our reviewer says that Iovera is 
not medically necessary. Our physician reviewer found that it is considered an experimental and investigational 
technique because there is little literature supporting its use for treating shoulder pain. Specifically, 
complication rates both short and long term are unknown as well as the incidence of neuroma formation. 
Therefore, the request is deemed not medically reasonable and necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Iovera have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Iovera.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the oxygen concentrator and mobility scooter 
purchased from September 22, 2022, to October 12, 2022. 
 
You asked the Plan to reimburse you for the durable medical equipment. You say that it was cheaper for you to 
purchase the oxygen equipment. You say that the scooter is necessary for you to get around. You also say that 
you should be reimbursed for these items. The Plan denied your request. The Plan says purchased oxygen 
equipment that is statutorily noncovered. The Plan says the wheelchair provider is not Medicare certified. The 
Plan also says that payment cannot be made to a provider that is not Medicare certified.  
 The Plan must follow Medicare rules. Medicare rules say that purchased oxygen equipment is statutorily non-
covered. Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the durable medical equipment have not been met. Therefore, we decided that the Plan does not 
have to reimburse you for the oxygen concentrator and mobility scooter purchased from September 22, 2022, 
to October 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 You asked the Plan to pre-approve Gel-One. You say that the enrollee would like to try this drug. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Durolane, 
Monovisc, or Synvisc-One. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gel-One. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided documentation does not 
support that the enrollee has trialed any of the preferred drugs. The reviewer found that the documentation does 
not outline contraindications or reasons these medications were not considered or that the Plans preferred 
drugs would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer 
found that the step therapy criteria for Gel-One have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.