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

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional non-emergency transportation trips. You say that you need 
these rides for your cancer treatment appointments. The Plan denied your request. The Plan says the requested 
transportation has exceeded the number of one-way non-emergency transportation trips allotted. 
 
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 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to approve additional 
non-emergency transportation trips for your cancer treatment appointments. 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 non-emergency transportation trips (A0100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and 
suspension sleeve (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the items are medically 
necessary. The Plan denied your request. The Plan says there is no evidence you have lymphedema extending 
onto the chest, trunk and/or abdomen that extends past the limits of a standard compression sleeve, and the 
chest, trunk and/or abdominal lymphedema has failed to improve with a four-week trial. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and suspension sleeve (E0667).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service November 22, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says one code must 
be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that the panel testing was not billed with a single code as required. 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 the panel testing billed for date of service November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intrauterine contraceptive device (IUD) provided on July 
26, 2022. 
 
You asked the Plan to pay for the IUD. You say that the service should be covered. The Plan denied your 
request. The Plan says this is not a covered service  
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing 
conception (contraception) are not considered medically reasonable and necessary.  
 
Records show that the requested service is primarily for the purpose of contraception. The documentation does 
not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for 
coverage of this item/service have not been met.. Therefore, we decided that the Plan does not have to pay for 
an intrauterine contraceptive device (IUD) provided on July 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown (D6750) and pontic (D6240). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 Plans 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. Therefore, we decided that the Plan does 
not have to pre-approve retainer crown (D6750) and pontic (D6240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attendant control (E2331), mounting bracket 
assembly (K0108), harness, seat multiplier (K0108), screws, pan head (K0108), and multiplier stud mount 
(K0108). 
 
  You asked the Plan to pre-approve an attendant control, mounting bracket assembly, harness, seat multiplier, 
screws, pan head, and multiplier stud mount. You say that the enrollee has been using a Quantum power chair 
with power seating, and has not misused the chair. You also say that the enrollee requires the requested new 
items so they are able to continue driving the chair independently in their home. The Plan denied your request. 
The Plan says an attendant control cannot be covered in addition to a beneficiary-operated joystick. The Plan 
says the mounting bracket assembly cannot be approved, as it is unbundled from the requested attendant 
control. The Plan also says that the harness, seat multiplier, screws, pan head, and multiplier stud mount cannot 
be approved because they are properly coded under another code. 
 
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 an attendant control, mounting bracket 
assembly, harness, seat multiplier, screws, pan head, and multiplier stud mount. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found an attendant control is not available with an individual control. Our reviewer also found that the 
bracket accessories are included in another code. 
 
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 attendant control, mounting bracket assembly, harness, seat multiplier, 
screws, pan head, and multiplier stud mount have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an attendant control (E2331), mounting bracket assembly (K0108), harness, seat multiplier 
(K0108), screws, pan head (K0108), and multiplier stud mount (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sacroiliac Joint Injection (SIJI). 
 
You asked the Plan to pre-approve a SIJI. You say that the service is medically necessary The Plan denied your 
request. The Plan says the service is not medically necessary 
 The Plan follows Medicare rules. Medicare rules say that Sacroiliac joint injections (SIJI) will be considered 
medically reasonable and necessary when all the requirement listed in 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 SIJI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found there is no documentation on physical 
examination of three (3) or more positive tests results. The clinical value and effectiveness of an SIJ injection 
in the absence of tenderness and negative provocative testing results have not been demonstrated in the peer-
reviewed literature. 
 
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 SIJI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Sacroiliac Joint Injection (SIJI).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on January 2, 2023. 
 
You asked the Plan to pay for the emergency room services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the provider is not enrolled in the 
Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the emergency room services provided 
on January 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on September 25, 2022. 
 You asked the Plan to pay for subsequent hospital care. You say that that the enrollee was not enrolled in 
hospice at the time of service. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 13, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for subsequent hospital 
care provided on September 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on May 27, 2021, billed with codes 
95886-26 x2, 95887-26, 95927-26-XS, and 95907-26. 
 
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 documentation does not support the billed codes. 
 
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 definitions of codes 95886-26 x2, 95887-26, 95927-26-XS, and 95907-26 
are; Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve 
conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three 
or more nerves or four or more spinal levels, Needle electromyography, non-extremity (cranial nerve supplied 
or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study, Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the 
central nervous system; in the trunk or head, and Nerve conduction studies; 1-2 studies. 
 
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 the testing services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the record shows that these services 
were performed as part of intraoperative neuromonitoring, not as a separately reportable diagnostic 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 the testing services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for testing services provided on May 27, 2021, billed with codes 95886-26 x2, 
95887-26, 95927-26-XS, and 95907-26.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on November 4, 2022. 
 
You asked the Plan to pay for initial hospital care (99223). You say that the inpatient consultation performed 
was in depth and went over all aspects of the enrollee's medical history and current medications. You say that 
the claim should be re-evaluated and paid appropriately. The Plan denied your request. The Plan says the 
medical records submitted do not support a comprehensive history. 
 
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 care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
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 initial hospital care (99223). Our reviewer says that the 
documentation does not support procedure code 99223. Our reviewer found the provided records do not 
document a chief complaint, an extended history of present illness, a review of all additional body systems and 
a complete past, family, and social history. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of initial hospital care (99223) have not been met. Therefore, we decided that the 
Plan does not have to pay for initial hospital care (99223) provided on November 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service February 25, 2023. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of 
service February 25, 2023.
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 reconsideration for the denial 
of an IRF admission based on medical necessity. The Plan denied your request. The Plan says your request 
for admission to an IRF 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) (K0553) and receiver for a CGM (K0554) provided on November 15, 2022.  
You asked the Plan to pay for the supply allowance and receiver for a CGM. The Plan denied your request. The 
Plan says this request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and the enrollee does not require frequent self-adjustment of insulin dosage 
based on the blood glucose testing results. Based on this information, we decided that Medicare rules for 
coverage of the supply allowance and receiver for a CGM have not been met. Therefore, we decided that the 
Plan does not have to pay for the supply allowance for a continuous glucose monitor (CGM) (K0553) and 
receiver for a CGM (K0554) provided on November 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism and a reclining chair (A9270, 
E0627). 
 
You asked the Plan to pre-approve a seat lift mechanism and a reclining chair. You say that you need the DME 
because you are only able to stand from chairs that have armrests. The Plan denied your request. The Plan says 
you are able to stand from chairs with armrests. You do not meet criteria for the seat lift mechanism. The Plan 
also says a reclining chair is not primarily used for a medical purpose. 
 
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. The rules also say that for equipment to be covered, it must 
primarily serve a medical purpose.   
 
We looked at the file and Medicare rules. Medicare rules say that a seat lift mechanism is covered if all the 
conditions are met, including you must be completely unable to stand up from a regular armchair or any chair 
in the home. You say that you can stand from chairs with armrests, therefore, you do not meet criteria for 
approval of the seat lift mechanism. The reclining chair requested does not serve a purpose that is primarily 
medical in nature. This item is available to the general public and would be helpful even to those who are not 
sick or injured. Based on this information, we decided that Medicare rules for coverage of a seat lift mechanism 
and a reclining chair have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
seat lift mechanism and a reclining chair (A9270, E0627).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued therapy services (codes 97161 and 97164) 
and therapeutic procedures (codes 97110 and 97112). 
 
  You asked the Plan to pre-approve the continued therapy services. You say that the therapy really helps to 
relieve your pain, and increase function so you can use your right hand for more activities of daily living. You 
also say that you have less pain now compared to when you first began, and you do not understand why your 
medical coverage has been denied. The Plan denied your request. The Plan says this determination is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 continued therapy services. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the requested therapy is not generally accepted as 
specific and effective therapy for your condition. The records do not demonstrate that the unique skills of a 
professional therapist are required to safely and effectively provide treatment, that the services can be safely 
and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the 
supervision of a therapist. Our reviewer also found that the requested services are part of a maintenance 
program, and do not require the specialized skill, knowledge, or judgement of a qualified therapist required to 
establish, design, and/or deliver a program to maintain your current condition or to prevent or slow further 
deterioration. 
 
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 continued therapy services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continued therapy services (codes 97161 and 97164) and therapeutic 
procedures (codes 97110 and 97112).