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

 
We decided that the Plan does not have to pay for the compression stockings device identified with code E0676 
and A9901 that were issued on December 7, 2022. 
 
You asked the Plan to pay for the compression stockings device. You say that you do not know why this is not 
being covered. The Plan denied your request. The Plan says the compression device that was purchased is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code E0676 
and A9901 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say 
that compression bandages and gradient compression wraps are covered only when they are used as dressings 
over a qualifying wound. 
 
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means 
that the enrollee does not have a medical condition for which compression stockings can be covered or paid for 
by Medicare. Therefore, we decided that the Plan does not have to pay for the compression stockings device 
identified with code E0676 and A9901 that were issued on December 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 99223 billed for date of service May 9, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity.  
 
 
 We find that CPT code 99223 is not supported in the medical record. Specifically, the records provided do not 
include a comprehensive history. 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 99223 billed for 
date of service May 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed, semi-electric (head and foot adjustment), 
with any type of side rails, with mattress (E0260). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the enrollee is quadriplegic and 
needs the requested bed. The Plan denied your request. The Plan says no additional information was presented 
to indicate that this is a medical necessity from the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a semi-electric hospital bed have been 
met. Specifically, several attempts were made to get the medical records and notes from the provider. The 
information was not received. Therefore, we decided that the Plan does not have to pre-approve a hospital bed, 
semi-electric (head and foot adjustment), with any type of side rails, with mattress (E0260).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Life2OOO Ventilator (E0466). 
 
You asked the Plan to pre-approve the Life2OOO Ventilator. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the item is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 Life2OOO Ventilator. Our reviewer 
says that the enrollee does not need this item. Our physician reviewer found there is no documented supporting 
data to state the enrollee needs or requires BIPAP or any ventilatory support to treat her stage of disease 
process. Further data is needed to make appropriate determination of ventilator need. 
 
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 Life2OOO Ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Life2OOO Ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Kinova O110 mechanical arm system. 
 
You asked the Plan to pre-approve a Kinova O110 mechanical arm system. You say that the items are 
medically necessary. The Plan denied your request. The Plan says the items 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 a Kinova O110 mechanical arm system. 
Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is minimal literature on the device's impact in quadriplegia. The devices, 
when used, have variable impact on function and do not have published evidence of predictable impact on 
Activities of Daily Living (ADLs) function. 
 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 Kinova O110 mechanical arm system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Kinova O110 mechanical arm system.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing care. 
 You asked the Plan to pre-approve home health services. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee is noted to have had a stroke over three years ago without a change in her current medical conditions 
or neurological status. There is limited clinical documentation in terms of the enrollees current level of 
function and mobility as well as her motor strength and range of motion. More clinical information is needed to 
determine the enrollees potential for responding to physical therapy versus requiring ongoing assistance. 
Therefore, continued home health services are not 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from February 1, 
2023, to February 23, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you had to remain in the SNF to 
receive treatment that you were unable to receive at home. 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 $0 
copayment for days 1 to 20 and a $50 copayment per day for days 21 to 100 for SNF care.  
 
 You have been asked to pay $700 for a SNF stay ($50 per day x 14 days = $700). This item/service falls within 
the SNF care 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 copayment for a SNF stay provided from 
February 1, 2023, to February 23, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 You asked the Plan to pre-approve Gelsyn-3. You say that you are in terrible pain and are having trouble 
walking. You say that you are afraid of falling and the pain is affecting your sleep and daily life.  The Plan 
denied your request. The Plan says that the step therapy requirements have not been met. 
 
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 Gelsyn-3. Our reviewer says that 
Gelsyn-3 is not medically necessary. Our physician reviewer found that you have not tried and failed the Plan's 
required dugs Monovisc, Synvisc or Orthovisc. The documentation does not outline contraindications or 
reasons the preferred medications were not considered or that the Plan's required drugs would likely be less 
effective or likely have adverse effects on you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the intraoral 
radiographic images (D0220), the cone beam (D0364), the pulp vitality test (D0460), and the core buildup 
(D2950) for tooth #9 provided on March 30, 2023, April 5, 2023, and April 11, 2023. 
 You asked the Plan to pay for the dental services. You say that the provider has billed for services that were not 
completed. The Plan denied your request. The Plan says your benefit for the limited oral evaluation and the 
intraoral radiographic images has already been exhausted. Also, the cone beam, the pulp vitality test, and the 
core buildup are not covered by the Plan. Dental records also verified that the dental services were completed 
on the dates of 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, certain limitations apply. The record 
shows the Plan paid for a limited oral evaluation (D0140) and the intraoral radiographic image (D0220) on 
February 21, 2023; therefore, your benefit for the limited oral evaluation and the intraoral radiographic images 
was exhausted on the date of service of February 21, 2023. The cone beam, the pulp vitality test, and the core 
buildup are not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to 
pay for the limited oral evaluation (D0140), the intraoral radiographic images (D0220), the cone beam 
(D0364), the pulp vitality test (D0460), and the core buildup (D2950) for tooth #9 provided on March 30, 2023, 
April 5, 2023, and April 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automatic blood pressure monitor (A4670). 
 
You asked the Plan to pre-approve an automatic blood pressure monitor. You say that the requested item is a 
necessity for the enrollees care. The Plan denied your request. The Plan says rules for coverage for an 
automatic blood pressure monitor have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor 
(A4670).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pump for a water circulating pad (E0236). 
 
You asked the Plan to pre-approve a pump for a water circulating pad. You say that the requested pump is 
medically necessary due to unilateral primary osteoarthritis of the right knee. The Plan denied your request. 
The Plan says the requested pump is denied as not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that because a water circulating heating pad system is 
not medically necessary, a replacement pump or pad will be denied as not reasonable and necessary. 
.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a pump for a water circulating pad have not been met. Specifically, it is not a covered benefit and 
is denied as not reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve a 
pump for a water circulating pad (E0236).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a reline complete maxillary denture (direct) (D5730) 
provided on March 15, 2023. 
 
You asked the Plan to pay for the reline complete maxillary denture. You say that the only teeth you have are a 
few on the bottom to keep the lower denture in place. You also say that the only dental work you needed were 
dentures. The Plan denied your request. The Plan says there is no coverage for reline complete maxillary 
denture (D5730). 
 
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 pay for a reline 
complete maxillary denture (direct) (D5730) provided on March 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 23, 2023. 
 
You asked the Plan to pay for the lab services. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on January 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652), a segmental 
pneumatic appliance for use with pneumatic compressor, trunk (E0656) and a segmental pneumatic appliance 
for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you are 
requesting reconsideration due to medical necessity. The Plan denied your request. The Plan says the request is 
not medically necessary because the enrollee does not have documentation that she completed a four-week trial 
of regular, daily, multiple-hour home usage of the E0650 or E0651. In addition, the provider notes indicate that 
the enrollee has chronic venous insufficiency as a cause of lymphedema. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652), a segmental pneumatic appliance for use with pneumatic compressor, trunk (E0656) and a segmental 
pneumatic appliance for use with pneumatic compressor, full leg (E0667).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an excision of excessive skin and subcutaneous tissue 
(includes lipectomy); thigh (15832). 
 
You asked the Plan to pre-approve the excision of excessive skin. You say that this is medically necessary for 
your health condition. The Plan denied your request. The Plan says this is considered cosmetic. The Plan also 
says that cosmetic procedures are not covered.  
 
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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the excision of excessive skin have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an excision of excessive skin and subcutaneous tissue (includes lipectomy); thigh (15832).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87500, and 87801 for date of service 
March 14, 2023. 
 
You asked the Plan to pay for procedure codes 87150, 87500, and 87801. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed are not supported. 
 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 codes 87150, 87500, and 87801 are not supported in the medical record. Specifically, code 
87150 was billed with modifier XU. The documentation does not support that procedure code 87801 was 
distinct or independent from other services performed; therefore, the use of XU modifier is not supported. 
The submitted medical records do not include lab test; therefore, code 87500 cannot be supported. Without 
identification and documentation of the tests that are represented by code 87798 that was billed on the same 
claim, confirmation that multiple organisms represented by code 87801 cannot be verified. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 87150, 87500, and 87801 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87150, 87500, and 
87801 for date of service March 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator (E0466). 
 
You asked the Plan to pre-approve a home mechanical ventilator . You say that the item is medically necessary. 
The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide continuous positive airway pressure (CPAP) or bi-level CPAP therapy will be denied as not reasonable and 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 a home mechanical ventilator. Our 
reviewer says that the item is not medically necessary. Our physician reviewer found there is no diagnosis of 
COPD, thoracic restrictive disease, or neuromuscular disease.  
 
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 home mechanical ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home mechanical ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on April 12, 2023. 
 
You asked the Plan to pay for the refraction . You say that the refraction should be paid. The Plan denied your 
request. The Plan says the service was not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when received as a part of a routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was not provided during a routine eye 
exam. The medical record shows a diagnosis of blurriness which makes the exam medical in nature. Based on 
this information, we decided that the Plan's rules for coverage of the refraction have not been met. Therefore, 
we decided that the Plan does not have to pay for the refraction provided on April 12, 2023.