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

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says that a power wheelchair and the requested 
accessories are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the enrollee does not have skin breakdown and is not at high risk for skin breakdown. The enrollee does not use intermittent 
catheterization and does not have spasticity. As the PWC base is not medically necessary, the requested 
accessories are not covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the magnetic resonance imaging (MRI) shows disc bulges at multiple levels and there 
is no documented six (6) months of treatment for back pain. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (64628).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel (80050) provided on February 1, 
2022. 
 
You asked the Plan to pay for the general health panel. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code billed is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
(80050) provided on February 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. 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 
experimental/investigational. 
 
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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the magnetic resonance imaging (MRI) of the lumbar spine does not show modic 
endplate changes. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Praluent. 
 
You asked the Plan to pre-approve Praluent. You say that Praluent has been previously approved to treat the 
enrollee. The Plan denied your request. The Plan says self-administered drugs do not fall under Medicare Part 
B coverage. 
 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 Praluent.  
 
Benefits for Praluent 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: 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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet the Medicare criteria for admission to an IRF. You can 
safely receive the services you need in other settings, for example: a skilled nursing facility, home with home 
health services or perhaps home with outpatient therapy. 
 
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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6534. 
 
You asked the Plan to pre-approve the compression stockings. You say that you need the compression 
stockings to help with blood circulation and to be able to work properly. You also say that when your ulcers 
erupt you bleed and it takes a long time to heal. The Plan denied your request. The Plan says you do not have a 
qualifying wound for coverage of compression stockings. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6534 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6534.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on November 28, 2022, billed 
with code 73140. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was not billed with an appropriate code 
for the services provided. 
 
The Plan must follow Medicare rules. Medicare rules say that when the diagnosis specifies that the condition 
occurs on the left or right side, the procedure code must be billed with the correct anatomical modifier.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiology services provided have not been met. This claim was billed with diagnosis code 
S62.625A, described as displaced fracture of middle phalanx of left ring finger, initial encounter for closed 
fracture. The procedure code was not billed with the correct modifier. Therefore, we decided that the Plan does 
not have to pay for radiological services provided on November 28, 2022, billed with code 73140.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to approve the PT visit. We decided that the Plan does not have to waive the 
copayment for laboratory services, PT evaluation, and an office visit.  
 
You asked the Plan to waive the cost for laboratory services, PT services, and an office visit provided on 
November 22, 2022, by an out-of-network provider. You say that you were not aware you would be 
responsible for out-of-network cost share for services rendered. The Plan says that the copayment applied 
correctly to the laboratory services, PT evaluation, and office visit. The Plan also says that an authorization was 
not obtained prior to the physical therapy visit being rendered. 
 
We decided that the Plan has to approve the PT visit provided by an out-of-network provider.  
 
The Plan says that authorization was not obtained for the physical therapy visit.  However, the EOC clearly 
states if no authorization is received, the Plan will cover the service under the out-of-network benefit where 
your share of the costs for your covered services will be higher. This means that the Plans denial for no prior 
authorization is not valid. Therefore, we decided that the Plan has to approve PT services.  
 
We also decided that the Plan does not have to waive the cost for laboratory services, PT evaluation, and 
an office visit provided by an out-of-network provider. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). The contract clearly states you are responsible for 20% 
coinsurance for out-of-network laboratory services, a $60 copayment for out-of-network PT services, and a $50 
copayment for an out-of-network office visit. Therefore, we decided that the Plan does not have to waive the 
cost for laboratory services, PT evaluation, and an office visit. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fosfomycin powder, a self-administered drug. 
 
You asked the Plan to pre-approve a self-administered drug. You say that the enrollee requires the self-
administered drug to treat recurring urinary tract infections. The Plan denied your request. The Plan says the 
medication is not covered as a medical benefit under the Plan. 
 
  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 Fosfomycin powder, a self-
administered drug.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for retainer crowns (D6740) for tooth #12, #13 and #15 and a pontic 
(D6245) for tooth #14 provided on October 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe a claim being denied for a 
procedure performed three years ago and paid by another insurance company is unacceptable. The Plan 
denied your request. The Plan says that your limit for this benefit has been reached. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan says the benefit for a bridge has already been exhausted due to you 
receiving a bridge in 2019. You did not enroll in this plan until 2021, and there is no evidence showing the Plan 
previously paid for that bridge to exhaust the current benefit. This means that the Plan has not provided a valid 
reason for denying payment of the dental services. Therefore, we decided that the Plan has to pay for retainer 
crowns (D6740) for tooth #12, #13 and #15 and a pontic (D6245) for tooth #14 provided on October 19, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested Intracept procedure is 
medically necessary. The Plan denied your request. The Plan says the requested Intracept procedure is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not medically necessary. Our physician reviewer found the 
magnetic resonance imaging (MRI) shows foraminal stenosis. The cause of back pain is unclear. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve an office visit to be provided by an out-of-network provider. You say that 
you are a 70-year-old woman who lives alone and you have an older model car. You say that you are very 
worried about having to drive a far distance by yourself as you are going to require additional medical 
treatment in an attempt to find the cure or resolution to your illness, which puts you at a higher risk of stroke 
and/or heart disease. The Plan denied your request. The Plan says your benefit plan does not cover out-of-
network providers except in cases of emergency. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron. 
 
You asked the Plan to pre-approve Ondansetron. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 Ondansetron.   
Benefits for Ondansetron 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99221 billed for date of service September 
30, 2022. 
 
You asked the Plan to pay for procedure code 99221. You say that this service was provided by a different 
provider. The Plan denied your request. The Plan says payment for code 99221 is bundled into payment for 
code 01470. 
 
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, we have confirmed that code 99221 is a column II code to column I code 01470 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99221 billed for date of service September 30, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for SNF care provided from June 10, 2022, through June 16, 2022. 
 
You asked the Plan to pay for SNF care. You say that you are unable to get out of a sitting position without 
assistance and need help using the bathroom. The Plan denied your request. The Plan says that the enrollee no 
longer had skilled nursing facility needs. 
 
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 pay for SNF care. Our reviewer says that the Plan 
has failed to provide sufficient records to support the denial. Our physician reviewer found that the 
documentation states the enrollee can walk 95 feet and is able to function without assistance. No such records 
have been provided; therefore, the initial denial is not supported. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pay for SNF care provided 
on June 10, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walking boot billed with code L4361 for date of service 
August 29, 2022. 
 
You asked the Plan to pay for the walking boot. You say that this item was provided following your 
reconstruction surgery and should be covered. The Plan denied your request. The Plan says the provider did not 
bill this item correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must append the KX modifier to 
claims to show that all coverage criteria for the item have been met. The provider that supplied you with this 
walking boot did not bill this item with this modifier as required.  You may contact the provider that supplied 
you with this boot to request that they correct their billing. Therefore, we decided that the Plan does not have to 
pay for the walking boot billed with code L4361 for date of service August 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transportation services beyond May 24, 2023. 
 
You asked the Plan to pre-approve transportation services beyond May 24, 2023. You say that you need 
transportation for wound care through June 2, 2023. The Plan denied your request. The Plan says you are not 
eligible for trips beyond May 24, 2023. 
 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 up to 12 one-way rides to and from medically related appointments and to the pharmacy 
for up to 30 days following all inpatient and skilled nursing facility discharges.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation beyond May 24, 2023, have not been met. Therefore, 
we decided that the Plan does not have to pre-approve transportation services beyond May 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cleaning and inspection of a removable complete 
denture, maxillary (D9932), and the complete denture, mandibular (9933). 
 
 
 You asked the Plan to pre-approve cleaning and inspection of the maxillary and mandibular dentures. You say 
that you have an upper appliance and it has to be professionally removed and cleaned. You also say that the in-
network dentist refused to work on your mouth stating he would not work on someone else's work. The Plan 
denied your request. The Plan says these services are not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve cleaning 
and inspection of a removable complete denture, maxillary (D9932), and the complete denture, mandibular 
(9933).