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

 
We decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) machine 
provided on February 07, 2023. 
 
You asked the Plan to pay for a continuous positive airway pressure (CPAP) machine. You say that you called 
this facility and they said they took your Plan. This should be paid for. 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 a continuous positive 
airway pressure (CPAP) machine provided on February 07, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC testing provided on November 11, 
2022. 
 
You asked the Plan to pay for the DecisionDx-SCC testing. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process.  
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC testing provided on 
November 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic nuclear medicine procedure 
provided on November 21, 2022. 
 
You asked the Plan to waive the copayment for diagnostic nuclear medicine procedure. You say that you are 
requesting reconsideration. 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 $350 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $350 copayment for diagnostic nuclear medicine procedure. This item/service 
falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for diagnostic nuclear medicine procedure provided on November 21, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC testing provided on December 20, 
2022. 
 
You asked the Plan to pay for the DecisionDx-SCC testing. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process.  
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC testing provided on 
December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
November 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that your last provider did not do a good job with 
your cleanings, and you sought out a new provider. The Plan denied your request. The Plan says your benefit 
for the requested item or service has already been exhausted. 
 
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 your benefit for the requested item or service was exhausted on date of service May 26, 2021. Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
November 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on December 
14, 2022. 
 
You asked the Plan to pay for the dental services. You say that your provider is in-network, and you are not 
accountable for this service. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
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 your benefit for the requested item or service was exhausted on date of service January 6, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation provided on 
December 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say the enrollee is at high risk of falling and sustaining an 
injury/wound that would require re-hospitalization. You also say the enrollee is at a very high risk of 
developing deep vein thrombosis (DVT) and/or pulmonary embolism (PE) as they are currently struggling to 
ambulate and move around their house. The Plan denied your request. The Plan says criteria for admission to 
the IRF have not been met. 
 
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 complexity of the enrollees nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the enrollee may have a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 7, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services are separately 
payable. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a foam mattress with gel pad. 
 
You asked the Plan to pre-approve a mattress with gel pad. You say that the piece of foam you were given is 
falling apart. You say that you do not need a Tempurpedic mattress specifically, only something similar. You 
also say that you are getting pressure sores. The Plan denied your request. The Plan says the requested mattress 
does not serve a medical purpose and therefore is not a covered benefit. 
 
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 foam mattress with gel pad.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a motorized/power wheelchair (K0010) purchased 
on August 18, 2021. 
 
You asked the Plan to reimburse you for a motorized/power wheelchair. You say that you want the Plan to 
reimburse you for this item. 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 a valid physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. 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 reimburse 
you for a motorized/power wheelchair (K0010) purchased on August 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950) 
provided on January 23, 2023. 
 
You asked the Plan to pay for the core buildup, including any pins. You say that you checked the EOC and 
coding and it looked like the claim should have gone through. The Plan denied your request. The Plan says if 
you receive a service not listed in the table, you will have to pay the full cost. 
 
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 core 
buildup, including any pins when required (D2950) provided on January 23, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 9, 2022 to 
February 7, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you do not believe that the admit 
date on the NOA and the claim have to match. The Plan denied your request. The Plan says the claim has not 
been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 9, 2022 to 
February 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87631 and 99072 billed for date of service 
October 4, 2022. 
 
You asked the Plan to pay for procedure codes 87631 and 99072. You say that these services are supported in 
the medical records. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. In addition, code 99072 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 procedure code. The rules also 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 procedure code 87631 
have not been met. 
 
In addition, we find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This 
means that procedure code 99072 is not separately payable. Based on this information, we decided that 
Medicare rules for coverage of code 99072 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 87631 and 99072 billed for date of service October 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for placement of intra-socket biological dressing to aid in 
hemostasis or clot stabilization (D7922) provided on January 5, 2023. 
 
You asked the Plan to pay for placement of intra-socket biological dressing. You say that this should be 
covered. The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for placement 
of intra-socket biological dressing to aid in hemostasis or clot stabilization (D7922) provided on January 5, 
2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a K3 lower limb prosthetic foot (L5981, L5986). 
 
You asked the Plan to pre-approve a K3 lower limb prosthetic foot. You say that this is medically necessary. 
The Plan denied your request. The Plan says that this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that specific criteria must be met for coverage. 
 
   
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 K3 lower limb prosthetic foot. Our 
reviewer says that the Plan erred in its denial of the requested foot. Not only does the medical record satisfy 
Medicare policy in demonstrating this beneficiary has K3 functional potential, but the Plan also attempts to 
create a more restrictive policy for defining K3 function than Medicare policy would allow. Our physician 
reviewer found in contrast to the broad, inclusive K3-criteria that are generally satisfied by the average 
Medicare enrollee who lives independently at home and can go out without meaningful restriction in the 
community, the Plans denial letter sets more stringent requirements than Medicare. In its own definition of the 
K3 level, the Plan seeks to create strict use-case criteria and a level of specificity that does not appear in the 
LCD - You must need to do more than simple walking...You must need to cross different barriers (such as 
walking long distances or walking on steep or slippery surfaces). Meanwhile, the Certified 
Prosthetist/Orthotist with corroboration from the surgeon, credibly establishes that there is no reason to expect 
that this enrollee will not return to unlimited community ambulation at a K3 level, per the guidelines quoted 
above, if supplied with the correct prosthesis.  
 
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 K3 lower limb prosthetic foot have been met. Therefore, we decided that the 
Plan has to pre-approve a K3 lower limb prosthetic foot (L5981, L5986).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted.  The Plan denied your request. The Plan says the requested IRF admission is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service December 
12, 2022. 
 You asked the Plan to pay for procedure code 76641. You say that the member had multiple exams done on 
this date of service. 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 claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polycarbonate or equal lenses (V2784) and 
photochromatic tint (V2744) provided on January 31, 2023. 
 
You asked the Plan to pay for the lens enhancements. You say that you are on a fixed income, and had you 
known about the additional cost, you would not have moved forward with your request. You also say that you 
assumed it was the responsibility of the employee to investigate what your insurance coverage for each service 
would be beforehand, and most importantly, if what the client is requesting will be covered or not. The Plan 
denied your request. The Plan says these items are not covered benefits. 
 
 
 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 does not cover enhancements. 
 
We looked at the file and the Plan's rules. The 2023 Evidence of Coverage clearly states that enhancements, 
including polycarbonate or equal lenses and photochromatic tint, are not covered by the Plan. Based on this 
information, we decided that the Plan's rules for coverage of the lens enhancements have not been met. 
Therefore, we decided that the Plan does not have to pay for the polycarbonate or equal lenses (V2784) and 
photochromatic tint (V2744) provided on January 31, 2023.