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

 
We decided that the Plan does not have to waive the coinsurance for oxygen equipment (E1390, E1392) 
provided on June 22, 2023, to July 5, 2023. 
 
You asked the Plan to waive the coinsurance for oxygen equipment. You say that you disagree with the denial. 
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 20% 
coinsurance for oxygen equipment.  
 
 
 
 You have been asked to pay a 20% coinsurance for oxygen equipment. This item/service falls within the 
durable medical equipment (DME) and related 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 coinsurance for oxygen equipment (E1390, E1392) provided on June 22, 2023, to July 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the breast prosthesis services provided on 
July 26, 2023. 
 
You asked the Plan to waive the coinsurance for the breast prosthesis services. You say that the cost share is 
too high. 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 20% 
coinsurance for prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for the breast prosthesis services. This item/service falls within 
the prosthetic devices and related 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. The total amount you owe is $141.09 ($705.52 allowed amount x 20% = 
$141.09). Therefore, we decided that the Plan does not have to waive the coinsurance for the breast prosthesis 
services provided on July 26, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you are requesting reconsideration for 
the denied claim. 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 you do not 
have documented skilled nursing needs. You do not have documented skilled therapy needs. There is no 
evidence of an acute illness or injury, requiring intermittent home health skilled services to assist in treatment.  
As such, the requested home health physical therapy/occupational therapy services are not medically necessary 
or reasonable. 
 
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 services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for injections provided from January 5, 2022, 
to September 29, 2023. 
 
You asked the Plan to waive the copayments for injections. You say that you feel these bills are unfair, as you 
didn't receive the statement until a year later. This is also a large amount to pay. 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 $25 
copayment for Medicare Part B prescription drugs.  
 
 
 You have been asked to pay a $750 total copayment for injections ($25 copayment x 30 injections = $750). 
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 copayments for injections provided from January 5, 2022, to September 29, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Minuteman G3R Interspinous device to L4-L5. 
 
You asked the Plan to pre-approve Minuteman G3R Interspinous device to L4-L5. You say that you are 
requesting reconsideration for the denied claim. The Plan denied your request. The Plan says the enrollee does 
not meet the requirements for approval. 
 
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 Minuteman G3R Interspinous device to 
L4-L5. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found minuteman procedure is experimental. More research 
needed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Minuteman G3R Interspinous device to L4-L5 have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Minuteman G3R Interspinous device to L4-L5.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Dayspring nonpneumatic compression device 
(K1024, K1025). 
 
You asked the Plan to pre-approve the Dayspring nonpneumatic compression device. You say that the items are 
medically necessary. The Plan denied your request. The Plan says this device is considered experimental. 
 
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 Dayspring nonpneumatic 
compression device. Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is insufficient evidence in the medical literature to 
support that the requested Dayspring device is as effective as a pneumatic sequential compression device. 
 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 Dayspring nonpneumatic compression device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Dayspring nonpneumatic compression device 
(K1024, K1025).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services described by code 01992 performed 
on date of service January 11, 2023. 
 
You asked the Plan to pay for 01992. You say that 01992 should be paid as billed because the diagnosis code 
assigned is reimbursable and is supported by LCA A57361. The Plan denied your request. The Plan says 01992 
is denied because the diagnosis code assigned does not support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that M99.23 is not listed as a diagnosis code that 
supports medical necessity when billing procedure code 01992. 
 
We looked at the file and Medicare rules. In this case we have confirmed that procedure code 01992 was billed 
with a diagnosis of only M99.23, defined as subluxation stenosis of neural canal of lumbar region. No 
additional diagnoses were listed on the claim. We confirmed that per LCA A57361, M99.23 does not support 
medical necessity when billing 01992. As such, the denial of 01992 is appropriate. Based on this information, we decided that Medicare rules for coverage of 01992 have not been met. Therefore, we decided that the Plan 
does not have to pay for the anesthesia services described by code 01992 performed on date of service January 
11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extracorporeal photopheresis provided on July 24, 2023. 
 
You asked the Plan to pay for extracorporeal photopheresis. You say that extracorporeal photopheresis was 
medically necessary. The Plan denied your request. The Plan says extracorporeal photopheresis was not 
medically necessary.  
 
The Plan follows Medicare rules. Medicare rules say that extracorporeal photopheresis is covered when the 
criteria listed in the Medicare rules section of this decision 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 pay for extracorporeal photopheresis. Our reviewer 
says that the requested extracorporeal photopheresis is not considered medically reasonable and necessary. Our 
physician reviewer found that the records in this case document a diagnosis of double lung transplant rejection 
for which the extracorporeal photopheresis was provided on July 24, 2023. The provided records do not 
document the patient had any of the nationally covered indications for the service as defined in the Medicare 
NCD. These covered indications are cited as palliative treatment of skin manifestations of cutaneous T-cell 
lymphoma that has not responded to other therapy; acute cardiac allograft rejection refractory to standard 
immunosuppressive drug treatment; chronic graft versus host disease refractory to standard immunosuppressive 
drug treatment and bronchiolitis obliterans syndrome following lung allograft transplantation when 
extracorporeal photopheresis is provided under a clinical research study. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of extracorporeal photopheresis have not been met. Therefore, we decided that the 
Plan does not have to pay for extracorporeal photopheresis provided on July 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 12, 2023. 
 
You asked the Plan to pay for the testing. 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 testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on June 12, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (01992) provided on March 30, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed 
without the required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that when code 01992 is used and MAC has been 
provided, the QS modifier must be used. 
 
We looked at the file and Medicare rules. In this case, code 01992 was billed for monitored anesthesia care. As 
such, this code requires the use of modifier QS, per LCA A57361. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the anesthesia services (01992) provided on March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote physiologic monitoring services provided on July 31, 
2023. 
 
You asked the Plan to pay for remote physiologic monitoring services. You say that the enrollee could not 
choose an in-network provider. 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 remote physiologic 
monitoring services provided on July 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Ottobock Kenevo K3 microprocessor knee. 
 
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 a K3 microprocessor knee 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the requested Ottobock Kenevo 
knee exceeds the enrollee's medical needs. His current activities can be met with a mechanical knee. 
Additionally, the requested Ottobock Kenevo knee has features that exceed his medical and functional needs, 
such as an intuitive indoor bicycle function, three activity modes, a donning function, and charging with a foam 
cover. The enrollee's needs can be safely and effectively met with a less complex knee. 
 
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 an Ottobock Kenevo K3 microprocessor knee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic care provided on July 17, 2023. 
 
You asked the Plan to pay for the chiropractic care. You say that you are appealing the claim payment denial. 
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 chiropractic care 
provided on July 17, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service September 
10, 2023, to September 23, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that there arent any contracted providers in this 
patients geographic area able to provide home infusion therapy services for implanted intrathecal pumps. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service September 10, 2023, to September 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery provided on June 20, 
2023, to July 03, 2023. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that you do not agree with how 
you were billed for the service you received. 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 $250 
copayment for outpatient hospital services. 
 
You have been asked to pay a $250 copayment for the outpatient surgery. This item/service falls within the 
outpatient hospital services 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 the 
outpatient surgery provided on June 20, 2023, to July 03, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on May 22, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the panel should be billed 
with one bundled code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on May 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E0953, E1007, E1012, E2300, E2311, 
E2313, E2361, E2377, and K0108). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and additional items and accessories. 
The Plan denied your request. The Plan says the enrollee does not have medical need for multiple power 
options included with K0861 group 3 power wheelchair. The Plan also says the electronic connection, 
expandable controller harness, and expandable controller cannot be covered as it is not medically necessary to 
control the three requested power options through the joystick (drive interface). 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
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 criteria for coverage has not been met. Our 
physician reviewer found the enrollee has multiple sclerosis (MS), and can walk in their home. The enrollee 
uses a power wheelchair outside the home. Our reviewer found that the enrollee has intact skin and 5 out of 5 
strength in their left arm and 4 out of 5 strength in their right arm. Our physician reviewer also found that 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 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 multiple power options (K0861) and additional items and accessories (codes E0953, E1007, 
E1012, E2300, E2311, E2313, E2361, E2377, and K0108).