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

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
when three or more power seating functions/actuators/motors are provided, one unit of E2311, one unit of 
E2377, and one unit of E2313 are allowed. You also say that you would like this to be reviewed for approval of 
the necessary electronics for the power wheelchair. The Plan denied your request. The Plan says that although 
there are three requested power options (tilt, recline and elevating leg rests), there is not a medical need to 
control these power options through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee is non-ambulatory and requires a power 
wheelchair for mobility and performing their basic daily activities. The enrollee cannot perform pressure relief 
independently due to upper extremity weakness and rotator cuff injuries. Our reviewer found that the enrollee 
also has history of a pressure wound on the sacrum requiring wound vacuum placement. The enrollee requires 
a power wheelchair with power tilt and recline for adequate pressure relief and positioning. Our physician 
reviewer found that the enrollee requires power elevating leg rests for positioning of their lower extremities and 
spasticity. The complexity of their seating and positioning needs necessitates a more complex group 3 power 
wheelchair base. Our reviewer also found that the expandable controller with harness and electronic connection 
are necessary to operate the group 3 power wheelchair base and the three power options via a joystick. 
 
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 electronic connection, harness, and expandable controller have been met. 
Therefore, we decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).  
 
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 an occlusal guard  hard appliance, full arch (D9944). 
 
You asked the Plan to pre-approve the occlusal guard. The Plan denied your request. The Plan says this benefit 
is not covered. 
 
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 an 
occlusal guard  hard appliance, full arch (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for table tennis/ping pong from January 1, 2022, through 
December 31, 2022. 
 
You asked the Plan to pay for table tennis. You say that at your current club, ping pong is the only exercise 
offered and you play against much more challenging players, thereby benefiting much more. The Plan denied 
your request. The Plan says this is not a covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan reimburses up to 
$150 per calendar year towards your cost for membership in a qualified health club or fitness facility during the 
calendar year.  
 
 
  The Plans rules for coverage of gym benefits have not been met because table tennis is not a qualified gym 
membership. Therefore, we decided that the Plan does not have to pay for table tennis/ping pong from January 
1, 2022, through December 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair side guards (K0108). 
 
You asked the Plan to pre-approve wheelchair side guards . You say that the items are medically necessary. 
The Plan denied your request. The Plan says this item 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 wheelchair side guards (K0108).
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 the enrollee needs to regain strength and endurance 
and requires close medical management for their current medical needs. The Plan denied your request. The 
Plan says the enrollee does not meet the criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. 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 pre-approve the wheelchair unoccupied transit kit (K0108). 
 
You asked the Plan to pre-approve the wheelchair unoccupied transit kit . You say that the item is medically 
necessary. The Plan denied your request. The Plan says the transit option is used to strap the wheelchair to a 
vehicle to travel outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve the wheelchair unoccupied transit kit (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on November 08, 2022. 
 
You asked the Plan to pay for the home visit. You say that at the time of service the enrollee was residing in a 
nursing home. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit provided 
on November 08, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on January 30, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for physical therapy. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 physical therapy provided on January 30, 2023, by 
an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942 billed for date of service June 13, 
2022.   
You asked the Plan to pay for procedure code 76942. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 76942 is 1. The MAI value for this code is 3. You billed 3 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 76942 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 76942 billed for date of service June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ophthalmological services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve ophthalmological services. You say that Dr Lisa D Garbutt was able to 
correctly diagnose, and you would prefer to stay with this provider. The Plan denied your request. The Plan 
says this is available in-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 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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
ophthalmological services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with single power 
option (K0856) and additional items and accessories (codes E0955, E0956, E2607, E2620, E1002, E1012, 
E2359, E1028, E2300, E2310, E2313, E2323, E2377, K0108, and K0108). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that the medical documentation supports the need of the custom medical equipment being requested 
for the enrollee. The Plan denied your request. The Plan says the enrollee does not have a qualifying diagnosis 
causing mobility limitation for which K0856 group 3 power wheelchair is medically needed. The Plan says gel 
pads (K0108) and hooks (K0108) do not serve a medical purpose and cannot be covered. The Plan also says the 
expandable controller, harness and electronic connection are not medically needed.  
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
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 
and additional items and accessories. Our reviewer says that the enrollee does not meet the criteria for 
coverage. Our physician reviewer found the enrollee has rheumatoid arthritis and has used a power wheelchair 
for some time. Our reviewer also found that the enrollee does not have a neurological condition, myopathy, or 
congenital spinal deformity which are the diagnostic criteria for a group3 power wheelchair. 
 
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 and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power 
wheelchair with single power option (K0856) and additional items and accessories (codes E0955, E0956, 
E2607, E2620, E1002, E1012, E2359, E1028, E2300, E2310, E2313, E2323, E2377, K0108, and K0108).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
December 22, 2022, to December 29, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you did not have a 
room until later in your stay. 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 $475 
copayment per day for days 1-4 of each inpatient hospital stay. Your contract with the Plan also clearly says that you then pay a $0 copayment for any additional day of the same inpatient hospital stay.  
 
You have been asked to pay a $475 copayment per day for days 1-4 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been asked to pay after day 
four or for the day you were discharged. You have been asked to pay a total of $1,900 for the inpatient hospital 
stay ($475 copayment per day x 4 days = $1,900). 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 copayment for 
the inpatient hospital stay provided from December 22, 2022, to December 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the lab services and the Prolia injection 
provided on January 23, 2023, and the specialist office visit provided on February 23, 2023. 
 
You asked the Plan to waive the cost share for the lab services, the injection, and the specialist office visit. You 
say that you are being over charged. 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 $5 
copayment for lab service performed outside of the primary care provider setting. Your contract with the Plan 
also clearly says that you must pay 20% of the total cost for Part B covered drugs. Your contract with the Plan 
also clearly says that you must pay a $25 copayment for each specialist visit. 
 
You have been asked to pay a $5 copayment for the lab services provided on January 23, 2023. This 
item/service falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. 
You have also been asked to pay a $25 copayment for the specialist office visit provided on February 23, 2023. 
This item/service falls within the physician/practitioner services, including doctors office visits 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. 
 
You have also been asked to pay $270.12, which is 20% coinsurance of the allowed amount for the injection 
provided on January 23, 2023 ($1,350.60 allowed amount x 20% = $270.12). This item/service falls within the 
Medicare Part B prescription drugs 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 share for the 
lab services and the Prolia injection provided on January 23, 2023, and the specialist office visit provided on 
February 23, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of osteoporosis. The documentation does not support that the enrollee has a 
history of osteoporotic fracture or has tried or cannot use zoledronic acid. The documentation does not support 
that zoledronic acid would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services identified with code 87631 for date of 
service July 26, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. 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 laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
identified with code 87631 for date of service July 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the panniculectomy. 
 
You asked the Plan to pre-approve the panniculectomy. You say that  the panniculectomy is medically 
necessary. The Plan denied your request. The Plan says the panniculectomy is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 panniculectomy. Our reviewer says 
that the service is not medically necessary. Our reviewer found the record indicates that the enrollee has had 
weight loss. The record provided does not establish the presence of chronic intertrigo refractory to conservative 
medical treatment or functional impairment. The elements of the coverage criteria are not satisfied, and 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 panniculectomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the panniculectomy.