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

 
We decided that the Plan does not have to pre-approve a limited oral evaluation - problem focused (D0140), 
and intraorifice barrier (D3911). 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says your 
benefit for the limited oral evaluation - problem focused 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the intraorifice barrier is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve intraorifice 
barrier (D3911). The record shows your benefit for the limited oral evaluation - problem focused was 
exhausted on date of services February 9, 2023, and March 14, 2023. Therefore, we decided that the Plan does 
not have to pre-approve a limited oral evaluation - problem focused (D0140), and intraorifice barrier (D3911).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on December 08, 2022. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit provided on 
December 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on October 5, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the facility payment. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for inpatient hospital services 
under the Inpatient Prospective Payment System (PPS). These amounts are, with certain exceptions, payment in 
full to the hospital for inpatient operating costs. All items and non-physician services furnished to inpatients 
must be furnished directly by the hospital or billed through the hospital under arrangements.  
 
We looked at the file and Medicare rules. Payment for the requested services is included in facility payment. 
Based on this information, we decided that Medicare rules for coverage of the services have not been met. 
Therefore, we decided that the Plan does not have to pay for the services provided on October 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro orthotic device. 
 
You asked the Plan to pre-approve MyoPro orthotic device. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested 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 MyoPro orthotic device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found the enrollee has a diagnosis of multiple sclerosis since 2009 resulting in upper 
extremity partial paralysis. The enrollee has tried and failed physical and occupational therapy and Botox. The 
MyoPro Orthosis is not known to be effective, based on scientific evidence, professional standards and expert 
opinion, in improving health outcomes. The MyoPro is not the standard of care for this enrollees multiple sclerosis condition or in widespread use for this patient's condition based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this 
enrollee. There is insufficient evidence in the literature that this device will increase participation in bimanual 
activities. Therefore, the enrollee does not meet criteria for the requested device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro orthotic device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve MyoPro orthotic device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tuberculosis test (code 86480) billed for date of service 
September 13, 2022.  
You asked the Plan to pay for code 86480. You say that these services were medically necessary and should be 
paid. The Plan denied your request. The Plan says this screening test is not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, code 86480, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
tuberculosis test (code 86480) billed for date of service September 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the enrollee needs 
transportation for medical appointments. The Plan denied your request. The Plan says this request will exceed 
the maximum number of transportation trips allowed per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer solution. 
 You asked the Plan to pre-approve Injectafer solution.. You say that the enrollee had an unsatisfactory response 
to oral iron. The Plan denied your request. The Plan says there is no record from the prescriber showing that the 
enrollee has tried one of the preferred drugs and it hasn't worked, or that the enrollee has medical reasons that 
prevent her from using one of them.  
 
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 Injectafer solution. Our reviewer says 
that the criteria for coverage have not been met.  Our physician reviewer found the Plan requires a trial of drugs 
Ferrlecit, INFeD, or Venofer before they will approve the requested drug, Injectafer. There is no indication that 
the enrollee has tried and failed the required drugs. There is no indication that the Plan's required drugs would 
likely be less effective and/or likely have adverse effects for the 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 Injectafer solution. have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Injectafer solution.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an observation care visit (99223-57) provided on October 1, 
2022. 
 
You asked the Plan to pay for physician visit. You say that this was not billed as required by coding rules. The 
Plan denied your request. The Plan says you are appealing with supporting records. 
 
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 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. The definition of modifier -57 is an evaluation and 
management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of evaluation and management service. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for physician visit. Our reviewer says that this code does not 
meet criteria. Our reviewer found modifier -57 should be used for major procedures with a global period of 90 
days. Minor procedures should use modifier -25. The primary procedure 49321 has a global period of 10 days 
and is considered a minor procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physician visit have not been met. Therefore, we decided that the Plan does not 
have to pay for an observation care visit (99223-57) provided on October 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration for 
the denial of an IRF admission stating the enrollee would benefit and can tolerate an intensive rehabilitation 
program. The Plan denied your request. The Plan says the IRF services requested do not meet the requirements 
for approval.  
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 4, 2022, to June 29, 
2022. 
 You asked the Plan to pay for the home health services. You say that you have supplied the required NOA. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is May 5, 2022. The NOA was not received by the Plan until June 29, 2022. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services provided from 
June 4, 2022, to June 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000), and routine podiatry services 
(11750, 29799, 73630).  
 
You asked the Plan to pre-approve foot orthotics and routine podiatry services. You say that the services should 
be covered. The Plan denied your request. The Plan says these services are not covered benefits. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition.  Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000), and 
routine podiatry services (11750, 29799, 73630).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurances for the Durable medical equipment provided 
on October 12, 2022, to January 12, 2023. 
 
You asked the Plan to waive the coinsurances for durable medical equipment. You say that you are disputing 
the share cost. 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 20% 
coinsurance for each Durable medical equipment (DME) and related supplies.  
 
You have been asked to pay 20% coinsurance for each durable medical equipment. This item/service falls 
within the Durable medical equipment (DME) and related supplies 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 coinsurances for the Durable medical equipment provided on October 12, 2022, to January 12, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery and pay for the self-
administered drugs provided on November 23, 2022. 
 
You asked the Plan to waive the copayment for the outpatient surgery and pay for the self-administered drugs. 
You say that the services should be covered. The Plan denied your request. The Plan says this cost sharing was 
charged correctly and self-administered drugs are not covered. 
 
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 $360 
copayment for outpatient hospital services. Self-administered drugs are not covered. 
 
You have been asked to pay a $360 copayment for the outpatient surgery. This item/service falls within the 
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. Self-administered drugs are not covered. Therefore, we decided that the Plan does not 
have to waive the copayment for the outpatient surgery and pay for the self-administered drugs provided on 
November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99349 and 99490 billed for date of service 
April 18, 2022. 
 
You asked the Plan to pay for the billed services. You say that the services were provided in accordance with 
regulations.  The Plan denied your request. The Plan says the date of service does not align with the records.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT codes 99349 and 99490 are not supported in the medical record. Specifically, the records 
provided do not include documentation for the date of service at issue provided by the billed rendering 
provider. 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 codes 99349 and 99490 billed 
for date of service April 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PTA procedure. 
 
You asked the Plan to pre-approve a PTA. You say that the requested services are a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested 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 a PTA. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that the records fail to indicate that the enrollee is not a suitable candidate for carotid endarterectomy 
(CEA). Guidelines are clear that such a procedure would be authorized only if the enrollee were not a candidate 
for CEA. 
 
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 PTA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a PTA procedure.
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 May 25, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport, and ground 
mileage. You say that Medicare covers transportation to and from dialysis appointments.  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, basic life support, 
non-emergency transport, and ground mileage.  Our reviewer says that the ambulance services were not medically necessary. Our physician reviewer found the 
transportation via ambulance to and from hemodialysis 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, basic life support, non-emergency transport, 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 May 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Liquid CDx (F1LCDx) (0239U) 
provided on November 30, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the FoundationOne Liquid CDx. You say that the treating physician ordered the 
F1LCDx test to assist in treatment or the enrollee. The Plan denied your request. The Plan says enrollees must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the FoundationOne Liquid CDx (F1LCDx) 
(0239U) provided on November 30, 2022, 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 scooter. 
 
You asked the Plan to pre-approve the power scooter. You say that this item is medically necessary. The Plan 
denied your request. The Plan says the scooter is for use outside the home and records do not show that the 
enrollee can safely operate the scooter. 
 
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 pre-approve a power scooter.