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

 
We decided that the Plan has to pre-approve an electronic connection (E2311). 
 
You asked the Plan to pre-approve an electronic connection. You say that this is medically necessary. The Plan 
denied your request. The Plan says that this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that services are covered if they are 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 an electronic connection. Our reviewer 
says that the item is medically necessary. Our physician reviewer found the enrollee is non-ambulatory and 
requires a power wheelchair for mobility and performing his basic daily activities. He cannot perform pressure 
relief independently due to weakness and requires a power wheelchair with power tilt for adequate pressure 
relief and positioning. He also requires power elevating leg rests for positioning of his lower extremities and 
lymphedema. The complexity of his seating and positioning needs necessitates a more complex group 3 power 
wheelchair base. The electronic connection is necessary to operate the group 3 power wheelchair base and the 
power options, including tilt and elevating leg rests, via a joystick. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection have been met. Therefore, we decided that the Plan has 
to pre-approve an electronic connection (E2311).  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 72125 billed for date of service December 1, 2022. 
 
You asked the Plan to pay for code 72125. You say that this code is covered by the Medicare fee schedule and 
was medically necessary. The Plan denied your request. The Plan says no separate payment is allowed for this 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that STV-packaged services are services for which 
separate payment is made only if there is no service with status indicator S, T, or V reported on the same claim. 
If a claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged 
services are assigned status indicator Q1.  
In this case, the code at issue (72125) has a status indicator of Q1, meaning that it is an STV-packaged service.  
It was billed on the same claim with code 99284.  Code 99284 has a status indicator of V.  As a result, code 
72125 cannot be separately paid. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 72125 have not been met. Therefore, we decided that the Plan does not have to pay for code 
72125 billed for date of service December 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on September 13, 2022, billed with 
code 76706. 
 
You asked the Plan to pay for the testing services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the services provided were 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 pay for the testing services provided. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was a male between the ages of 65 and 75, there is no evidence that he 
had a family history of AAA, had smoked at least 100 cigarettes in his lifetime or had any other cardiovascular 
risk factors. As such, there is no evidence that the screening US was medically necessary or reasonable. 
 
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 testing services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for testing services provided on September 13, 2022, billed with code 76706.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the osseous, osteoperiosteal, or cartilage graft (D7950). 
 
You asked the Plan to pre-approve the extraction and osteoperiosteal, or cartilage graft. You say that you have 
not used your dental benefit in 5 years of coverage and denying this benefit would have an adverse financial 
impact to you. You also say that without this procedure your quality of life would suffer and you would remain 
disfigured. The Plan denied your request. The Plan says surgical reconstruction is not covered under this plan. 
 
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 osteoperiosteal, or cartilage graft is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
the osseous, osteoperiosteal, or cartilage graft (D7950).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 19085 billed for date of service December 7, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the diagnosis 
codes do not meet the requirements. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 19085 was billed with diagnosis codes C50.912, Z17.0, and Z85.3. The billed diagnosis 
codes are not among those covered for the billed service. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code 19085 billed for date of service December 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve a seat lift mechanism. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 seat lift mechanism. Our reviewer 
says that you need this medical item. Our physician reviewer found the documentation doesnt indicate that you have severe neuromuscular disease or that you are incapable of standing up from a regular armchair or any 
chair in your home. Additionally, it is not clear if you are able to ambulate once standing. 
 
 
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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration for the denial of an LTACH admission. The Plan denied your request. The Plan says the 
LTACH services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer  
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care setting. 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a hospital outpatient clinic visit provided 
on December 07, 2022. 
 
You asked the Plan to reduce the copayment for a hospital outpatient clinic visit. You say that you think that 
the copayment for this service should be lower. 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 $250 
copayment for in-network outpatient hospital services. 
 
You have been asked to pay a $250 copayment for a hospital outpatient clinic visit. This item/service falls 
within the in-network outpatient hospital 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. However, since the allowed amount is less than the standard 
copayment, you only owe $119.25. Therefore, we decided that the Plan does not have to reduce the copayment 
for a hospital outpatient clinic visit provided on December 07, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit provided on November 21, 
2022. 
 
You asked the Plan to pay for the emergency department visit. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were reimbursed by the Plan on [Please enter the date on which the prior claim was paid on December 6, 2022. Comparison of the two claims shows these are exact duplicates. Both providers have the same specialty and were billed under the same billing provider. There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit provided on November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0230). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the enrollee needs this type of bed 
due to muscle wasting and atrophy. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for a semi-electric bed. 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that this item is not medically necessary. Our physician reviewer found that the provided records 
in this case document that the enrollees condition requires the head of the bed to be elevated more than 30 
degrees due to chronic obstructive pulmonary disease, chronic respiratory failure and heart failure. The records 
do not document that the enrollee requires frequent changes in body position or immediate changes in body 
position. The enrollees condition does not require special attachments that cannot be fixed and used on an 
ordinary bed. A semi-electric bed is not medically reasonable and necessary for this enrollee. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0230).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration for the denial of an LTACH admission. The Plan denied your request. The Plan says your 
request for admission to an LTACH does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care setting. 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a zoomer mobility chair (K0899) purchased on May 23, 
2022. 
 
You asked the Plan to pay for a zoomer mobility chair. You say that you want the Plan to reimburse you for 
this item. The Plan denied your request. The Plan says Medicare defines durable medical equipment as an item 
that is medical in nature, can withstand repeated use, and is used in the home. The item requested/received does 
not meet these requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that the Zoomer Mobility Chair has not been 
categorized by the PDAC and thus is considered not reasonable and necessary. 
 
   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a zoomer mobility chair have not been met. Therefore, we decided that the Plan does not have to 
pay for a zoomer mobility chair (K0899) purchased on May 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nubeqa. 
 
You asked the Plan to pre-approve Nubeqa. You say that the requested drug is necessary for the enrollee. The 
Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare Part B. 
 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 Nubeqa.  
 
Benefits for Nubeqa may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341). 
 
You asked the Plan to pre-approve periodontal scaling and root planing. You say that this is medically 
necessary and you cannot afford to pay out of pocket. The Plan denied your request. The Plan says the 
requested service is not a covered benefit. 
 
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 pre-approve 
periodontal scaling and root planing (D4341).
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient services provided on April 26, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that non-participating provider requests later than 60 days following 
the date on the explanation of payment (EOP) are not processed by the Plan. The Plan also says the EOP for 
this claim was sent on June 29, 2022. 
 
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 forwarded any evidence to support their decision. 
The Plan has not forwarded the claim or denial to indicate what was billed, when or why it was denied. It is the 
burden of the Health Plan to substantiate their decision with evidence. In this case, the Plan's decision has not 
been substantiated. Therefore, we decided that the Plan has to pay for the outpatient services provided on April 
26, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the autonomic function testing performed on November 
10, 2022. 
 
You asked the Plan to pre-approve the autonomic function testing. You say that the service was medically 
necessary. The Plan denied your request. The Plan says the records do not indicate that the results of this test 
will be used in medical management of the enrollee's condition, and the device used is considered 
investigational 
 
The Plan follows Medicare rules. Medicare rules say that testing with ANSAR ANX 3.0 or a similar machine is 
considered investigational for screening and will not be 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 autonomic function testing. Our 
reviewer says that the service was not medically necessary. Our physician reviewer found the enrollee has a 
diagnosis of peripheral autonomic neuropathy, hypertension, and peripheral vascular disease. The record sent 
by the provider indicates the enrollee underwent testing with an ANSAR device on November 10, 2022. There 
is no indication that this testing will impact management. 
 
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 autonomic function testing have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the autonomic function testing performed on November 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you live alone and are currently a fall risk. You 
would benefit from therapy at the IRF. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.