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 and accessories (E0953, 
E0960, E1007, E1012, E2300, E2311, E2313, E2361, E2377, E2620, E2622, K0040, K0108, K0861). 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met.  

The Plan follows Medicare rules. Medicare rules say that a power mobility device is covered when specific 
criteria 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 group 3 power wheelchair and 
accessories. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
enrollee does not have high risk for skin breakdown, use a catheter intermittently, have spasticity or require an 
alternative means of managing power drive. 
 
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 power wheelchair and accessories have been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (E0953, E0960, 
E1007, E1012, E2300, E2311, E2313, E2361, E2377, E2620, E2622, K0040, K0108, K0861).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 62324 billed for date of service May 11, 
2023. 
 
You asked the Plan to pay for procedure code 62324. The Plan denied your request. The Plan says payment for 
code 62324 is bundled into payment for code 00792. 
 
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 62324 is a column II code to column I code 00792. The medical 
records do not show that code 62324, billed with the -59 modifier, was a distinct procedural service. 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 62324 billed for date of service May 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 30, 2023, billed with 
codes 87637, 87541, 87581, 87651, 87486, 87640, 87641, 87150, 87500, and 87801. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. The file shows that an upper respiratory infection panel test was provided. We looked at the file and Medicare 
rules. This NGS panel was not billed with a single code as required. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the genetic testing provided on May 30, 2023, billed with codes 87637, 87541, 87581, 
87651, 87486, 87640, 87641, 87150, 87500, and 87801.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain or ceramic crown (D2740) for teeth numbers 
14 and 15 and crown buildup (D2950) for teeth numbers 14 and 15. 
 
You asked the Plan to pre-approve a porcelain or ceramic crown (D2740) for teeth numbers 14 and 15 and 
crown buildup (D2950) for teeth numbers 14 and 15. You say that for teeth numbers 14 and 15, there are 
existing amalgam fillings, existing restoration larger than 50% tooth structure, fillings are breaking down 
around the borders and visible fracture lines. The Plan denied your request. The Plan says a clinical review of 
the documentation submitted for this claim determined a porcelain or ceramic crown (D2740) for tooth number 
14 and crown buildup (D2950) for tooth number 14 does not meet the criteria for coverage. The Plan also says 
that a porcelain or ceramic crown (D2740) for tooth number 15 and crown buildup (D2950) for tooth number 
15 does not meet the criteria for benefits as established by the Current Dental Terminology definition of this 
procedure. 
 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. The Plan covers a porcelain or 
ceramic crown (D2740) for teeth numbers 14 and 15 and crown buildup (D2950) for teeth numbers 14 and 15 
when the services are medically necessary and reasonable.  
 
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 porcelain or ceramic crown (D2740) 
for teeth numbers 14 and 15 and crown buildup (D2950) for teeth numbers 14 and 15. Our reviewer says that 
the enrollee does not meet the criteria for a porcelain or ceramic crown (D2740) for teeth numbers 14 and 15 
and crown buildup (D2950) for teeth numbers 14 and 15. Our physician reviewer found the image is blurry and 
pixelated, making it difficult to make a diagnosis. Our physician reviewer also found that based on the 
information provided, a porcelain or ceramic crown (D2740) for teeth numbers 14 and 15 and crown buildup 
(D2950) for teeth numbers 14 and 15 are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a porcelain or ceramic crown (D2740) for teeth numbers 14 and 15 and crown 
buildup (D2950) for teeth numbers 14 and 15 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a porcelain or ceramic crown (D2740) for teeth numbers 14 and 15 and crown buildup 
(D2950) for teeth numbers 14 and 15.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute with leg platform (E0118). 
 
You asked the Plan to pre-approve a crutch substitute with leg platform. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that a crutch substitute is a non-covered item.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the knee scooter have not been met. Specifically, this item is not a covered benefit of Medicare or 
the Plan. Therefore, we decided that the Plan does not have to pre-approve a crutch substitute with leg platform 
(E0118).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the standard wheelchair (K0001) and additional 
features/accessories. 
 
You asked the Plan to pre-approve the standard wheelchair and additional features/accessories. You say that 
the items are medically necessary. The Plan denied your request. The Plan says the enrollee has a wheelchair 
less than 5 years old and there is no explanation as to why this needs to be replaced. 
 
The Plan must follow Medicare rules. Medicare rules say that, in no case can the RUL of equipment be less 
than 5 years. The rules also say that replacement due to wear is not covered during the RUL of the equipment.  
 
The item being requested shows to be for replacement of an identical or nearly identical item, due to wear. The 
case file shows that the existing equipment is less than 5 years old. This means that replacement of this equipment due to wear is not covered at this time. Therefore, we decided that the Plan does not have to pre-
approve the standard wheelchair (K0001) and additional features/accessories.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for a cystourethroscopy (52000) provided on August 3, 2023, by 
an out-of-network (OON) provider.  

You asked the Plan to pay for a cystourethroscopy with an out-of-network provider. . You say that the service 
was billed correctly, and you want the Plan to pay. The Plan denied your request. The Plan says this provider is 
not a network provider. The service was not urgent or emergent, nor was it approved in advance. 
 
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 a cystourethroscopy (52000) provided on August 
3, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a back brace (L0650) provided on May 30, 2023. 
 
You asked the Plan to pay for a back brace. You say that the item was medically necessary. The Plan denied 
your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. There is no indication the brace was needed or ordered in the clinical documentation submitted. The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for a back brace (L0650) provided on May 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in tub (E1399). 
 
You asked the Plan to pre-approve a walk-in tub. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this is an item of convenience and does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal 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. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in tub (E1399).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Farxiga. 
 
You asked the Plan to pre-approve the medication. You say that the requested drug is medically necessary for 
the enrollee. 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 Farxiga.  
 
Benefits for the medication 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on July 20, 2023. 
 
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the Place of Service (POS) code billed on this claim is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. This claim was billed with POS code 81  indicating an independent 
laboratory setting  however, the record does not support that the sample for this testing was taken directly in 
the independent laboratory setting. Based on this information, we decided that Medicare rules for coverage of 
drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing 
provided on July 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sprint PNS system. 
 
You asked the Plan to pre-approve the sprint PNS system. You say that you are in severe pain and cannot 
function. You say that you do not have a quality of life due to the pain. The Plan denied your request. The Plan 
says the sprint PNS system 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 sprint PNS system. Our reviewer 
says that the sprint PNS system is not medically necessary. Our physician reviewer found that the sprint PNS 
device request is not for a trial for a permanently implanted device and as the sprint PNS electrodes and battery 
are neither permanent nor surgically implanted, the requested device does not meet the criteria for coverage. 
 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 sprint PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the sprint PNS system.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93005 provided on March 28, 2023. 
 
You asked the Plan to pay for procedure code 93005. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code billed is not separately payable. 
 
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 CPT code 93005 is not supported in the medical record. Specifically, code 93005 is listed with a 
status indicator Q1. This code was billed the same date of service as code 99285, which has a status code V 
and CPT 71046, which has a status code S. Payment for code 93005 is bundled. Based on this information, 
we decided that Medicare rules for coverage of procedure code 93005 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93005 provided on March 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization (PAE). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found prostatic arterial embolization (PAE) is 
considered an experimental technique to treat symptomatic benign prostatic hyperplasia (BPH). Very limited 
studies have demonstrated possible short-term safety and efficacy.  The most recent American Urological 
Association (AUA) guidelines do not recommend this procedure outside of a clinical trial setting due to the 
heterogeneity in the available literature and safety concerns regarding radiation exposure, postembolization syndrome, vascular access, technical feasibility, higher clinical failure rate compared with more traditional 
methods (eg, transurethral resection of the prostate [TURP]). The services are therefore not reasonable or 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve prostate artery embolization (PAE).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the high frequency chest wall oscillation air-pulse 
generator system (HFCWO (E0483). 
 
You asked the Plan to pre-approve the HFCWO. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the records show the enrollee does not have a qualifying disease or condition, such 
as a diagnosis of cystic fibrosis, bronchiectasis, or a neuromuscular disorder.  
 
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall 
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve the high frequency chest wall oscillation air-pulse generator system (HFCWO (E0483).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81455) provided on January 9, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. 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 lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (81455) provided on 
January 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the CGM is necessary because you need to control 
your diabetes and your A1C is high. The Plan denied your request. The Plan says the Medicare criteria was not 
met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the record provided does not indicate 
that the enrollee is being treated with insulin or has problematic hypoglycemia as defined by the Medicare 
rules. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 29505 billed for date of service May 8, 2023.

You asked the Plan to pay for procedure code 29505. You say that the medical records support the billing. The Plan denied your request. The Plan says payment for code 29505 is bundled into payment for code 27502.

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 29505 is a column II code to column I code 27502. Providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. The medical records do not show that code 29505, billed with the -59 modifier, was a distinct procedural service. 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 29505 billed for date of service May 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attendant control (E2331). 
 
You asked the Plan to pre-approve an attendant control. You say that the enrollee requires the K0861 base and 
all recommended components to meet their mobility, medical and functional needs in their home. The Plan 
denied your request. The Plan says this item still does not meet the coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that if an attendant control (E2331) is provided in addition 
to a beneficiary-operated drive control system, it will be denied as non-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. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the enrollee uses a power 
wheelchair because they have cerebral palsy. Our reviewer also found that the enrollee has a standard joystick 
and is able to move independently between rooms. 
 
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 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an attendant control (E2331).