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

 
We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627). 
 
You asked the Plan to pre-approve a seat lift mechanism. You say that this is medically necessary. The Plan 
denied your request. The Plan says this 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 the item is not medically necessary. Our physician reviewer found you are noted to have knee pain 
and osteoarthritis. You are limited with mobility and requires supplemental oxygen but can ambulate in your 
home with a walker. However, the physical therapy documentation indicates that you are modified independent 
with sit to stand transfers with the use of your walker and has 4/5 motor strength in your lower extremities. 
 
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 (E0627).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you have problems walking, need assistance 
dressing, and have impaired communication skills. You say SNF services would enable you to stay at home 
longer. The Plan denied your request. The Plan says criteria for admission to a SNF have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power options (K0861) and additional items/accessories (codes E2300, E1028, E2311, E2313, E2377, E1028, 
E1002, E1012, E2361, E0955, and E2603). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair with multiple power options and 
additional items/accessories. The Plan denied your request. The Plan says this request is not deemed medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a power mobility device (PMD) will not be covered if 
the patient does not have mobility deficit that impairs their participation in Mobility-Related Activities of Daily 
Living (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 group 3 standard power wheelchair 
with multiple power options and additional items/accessories. Our reviewer says that you do not meet the 
coverage criteria for a group 3 standard power wheelchair with multiple power options. Our physician reviewer 
found you can walk a short distance with a quad cane. Our reviewer found that your condition does not require 
multiple power drives because you are not at high risk for skin break down, have no catheter use and no 
spasticity. 
 
 
 
 
 
 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 group 3 standard power wheelchair with multiple power options and 
additional items/accessories have not been met. Therefore, we decided that the Plan does not have to pre-
approve a group 3 standard power wheelchair with multiple power options (K0861) and additional 
items/accessories (codes E2300, E1028, E2311, E2313, E2377, E1028, E1002, E1012, E2361, E0955, and 
E2603).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gas to help you relax (D9230), placement of intra-socket 
biological dressing to aid in hemostasis or clot, stabilization, per site (D7922 x3), tooth removal of roots 
(extraction) (D7250 x2), and unspecified oral surgery procedure, by report (D7999). 
 
You asked the Plan to pre-approve dental services. You say that these should be covered. The Plan denied your 
request. The Plan says these are not covered services. 
 
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 gas 
to help you relax (D9230), placement of intra-socket biological dressing to aid in hemostasis or clot, stabilization, per site (D7922 x3), tooth removal of roots (extraction) (D7250 x2), and unspecified oral surgery 
procedure, by report (D7999).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the drug injection provided on January 10, 2023. We 
also decided that the Plan does not have to waive the cost share for the nuclear medicine heart study and 
medical supplies provided on January 10, 2023.   You asked the Plan to waive the cost share for the nuclear medicine heart study, medical supplies, and drug 
injection. You say that you should not have to pay because this was something the doctor ordered. The Plan 
denied your request. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the coinsurance for the drug injection.  
 
The enrollee has been asked to pay 20% coinsurance for the drug injection. According to Medicare, the 
injection (code J2785) is considered a packaged code and is not separately payable. This code is also excluded 
from the physicians free schedule. Therefore, we decided that the Plan has to waive the coinsurance for the 
drug injection provided on January 10, 2023.  
 
We also decided that the Plan does not have to waive the cost share for the nuclear medicine heart study 
and medical supplies. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). The enrollees contract with the Plan clearly says that the enrollee 
must pay a $300 copayment for in-network nuclear medicine heart studies. The enrollees contract with the 
Plan also clearly says that the enrollee must pay 20% coinsurance for in-network medical supplies. 
 
The enrollee has been asked to pay a $300 copayment for the nuclear medicine heart study. The enrollee has 
also been asked to pay $72, which is 20% coinsurance of the allowed amount for the medical supplies ($360 
allowed amount x 20% coinsurance = $72). These items/services fall within the outpatient diagnostic tests and 
therapeutic services benefit category. This means that the enrollee has been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
when they enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for 
the nuclear medicine heart study and medical supplies provided on January 10, 2023. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental implant (D6111). 
 
You asked the Plan to pre-approve a dental implant. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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 a 
dental implant (D6111).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes procedure codes 97112, 97530, and 97542 
billed for date of service November 8, 2022. 
 
You asked the Plan to pay for the billed services. You say that the documentation shows medical necessity. The 
Plan denied your request. The Plan says an appropriate modifier was not billed. 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 codes 97112, 97530, and 97542 were not billed with a KX modifier to indicate the enrollee 
qualifies for a cap exception. 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 
procedure codes 97112, 97530, and 97542 billed for date of service November 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter placement of an intravascular stent, of a 
cervical carotid artery (31275). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested service is not medically necessary 
because the records do not show that the enrollee has a high risk condition for carotid endarterectomy. 
 
The Plan must follow Medicare rules. The rules say that Concurrent with Carotid Stent Placement in Patients at 
High Risk for Carotid Endarterectomy (CEA), Medicare covers a Percutaneous Transluminal Angioplasty 
(PTA) of the carotid artery concurrent with the placement of a Food and Drug Administration (FDA) approved 
carotid stent with embolic protection for specifically indicated conditions.  
 
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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is the appropriateness and medical necessity of carotid PTA and stent placement in this 
enrollee. 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 he were not a candidate for 
CEA.  As such, PTA and stent placement would not be considered medically necessary in this enrollees 
clinical 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter placement of an intravascular stent, of a cervical carotid artery (31275).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization. 
 
You asked the Plan to pre-approve cardiac catheterization. You say that you disagree with the Plan's denial. 
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 cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee history of left heart cardiac catheterization in February 2023 showing 2-
vessel coronary artery disease for which staged coronary angioplasty (percutaneous coronary intervention) is 
planned several weeks after upcoming transcatheter aortic valve replacement procedure. Guidelines do not 
support a need for repeat left heart catheterization in this setting. As a result, at this time repeat left heart catheterization would not be considered medically appropriate and necessary in this enrollee's clinical 
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 cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the diagnostic mammogram, the digital 
breast tomosynthesis, and the breast ultrasound provided by an out-of-network provider on December 8, 2022. 
 
You asked the Plan to waive the cost sharing for the mammogram, the breast tomosynthesis, and the 
ultrasound. You say that you were not aware that the provider was out-of-network. 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 50% 
coinsurance for out-of-network Medicare-covered radiological diagnostic services, not including x-rays, 
performed in a physicians office or at a free-standing facility (such as a radiology center or medical clinic). You have been asked to pay a $177.07 coinsurance for the mammogram, the breast tomosynthesis, and the 
ultrasound ($354.13 allowed amount x .50 = $177.07 rounded up). These items/services fall within the 
outpatient diagnostic tests and therapeutic services and 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 cost sharing for the diagnostic mammogram, the digital breast tomosynthesis, and the breast 
ultrasound provided by an out-of-network provider on December 8, 2022.
Appeal type: Lab
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 21, 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 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88360 and 88381 billed for date of service 
May 19, 2022. 
 You asked the Plan to pay for procedure code(s) 88360 and 88381. You say that these services are supported in 
the medical record. The Plan denied your request. The Plan says this code is included in the facility payment 
and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88360 and 88381. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88360 and 
88381. Based on this information, we decided that Medicare rules for coverage of procedure code 88360 and 
88381 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 
88360 and 88381 billed for date of service May 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on August 31, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for wound care supplies. You say that the enrollee was treated and billing separately 
for theses supplies is appropriate. The Plan denied your request. The Plan says the provider is out-of-network.  
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 wound care supplies provided on August 31, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular stimulator billed for date of service 
September 14, 2022. 
 You asked the Plan to pay for the billed services. You say that E0475 is not experimental. The Plan denied 
your request. The Plan says the item was not billed as required. 
 
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 E0745 is a capped rental item. The claim did not include the appropriate modifier to 
indicate the item is to be rented. 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 
neuromuscular stimulator billed for date of service September 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 50715 billed for date of service November 
28, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code is 
inclusive to the primary procedure. 
 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 50715 is ureterolysis, with or without repositioning of 
ureter for retroperitoneal fibrosis. We find that CPT code 50715 was an integral part of procedure code 22558 
and not separately payable. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
50715 billed for date of service November 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is highly motivated and are willing to 
participate in 3 hours of therapy per day of acute rehab. The Plan denied your request. The Plan says an IRF 
admission 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 the enrollee does not need physician supervision 3 times a week or intensive 
therapy 3 hours a day and 5 days per week with a multidisciplinary approach in an IRF. While the enrollee may 
benefit from physical and occupational therapy the enrollee's needs can be provided in an alternate setting such 
as skilled nursing facility. 
 
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 IRF admission and services.