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

 
We decided that the Plan does not have to pre-approve a pneumatic propulsion tire (E2211), a pneumatic-tire 
removable insert (E2213), a foam caster tire (E2219), as well as impact guards, side guards and a privacy flap 
for a manual wheelchair. 
 
You asked the Plan to pre-approve a pneumatic propulsion tire, a pneumatic-tire removable insert, a foam 
caster tire, impact guards, side guards and a privacy flap. You say that the requested items are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested items are not a covered 
benefit. 
 
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 rules also say that for equipment to be covered, it must primarily serve 
a medical purpose. 
 
The pneumatic propulsion tire, pneumatic-tire removable insert and foam caster tire at issue in this appeal are 
for use outside of the home. Although these items may be helpful, neither Medicare nor the Plan covers 
equipment for use outside the home. Furthermore, the impact guards, side guards and privacy flap at issue in 
this appeal does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan 
does not have to pre-approve a pneumatic propulsion tire (E2211), a pneumatic-tire removable insert (E2213), 
a foam caster tire (E2219), as well as impact guards, side guards and a privacy flap for a manual wheelchair.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral and/or oropharyngeal suction catheter (A4628) and 
gauze, non-impregnated, sterile, pad size 16 square inches or less (A6402) provided on April 18, 2023. 
 
You asked the Plan to pay for a catheter and gauze. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says codes A4628 and A6402 
remain 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 asked our coder 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 a catheter and gauze. Our reviewer says that the service does 
not meet criteria for approval of payment on this claim. Our reviewer found for Healthcare Common Procedure 
Coding System (HCPCS) A4628; the documentation does not support the units billed. The statement of 
medical necessity for HCPCS code documents "2 per month", however delivery ticket shows 4 delivered, for 
dates of service, 4/18/2023 to 5/17/2023. Units billed are not supported in this case. For HCPCS A6402, 
documentation does not support the units billed.  Delivery ticket shows 1 trach sponge was delivered; therefore 
this procedure and units cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a catheter and gauze have not been met. Therefore, we decided that the Plan 
does not have to pay for an oral and/or oropharyngeal suction catheter (A4628) and gauze, non-impregnated, 
sterile, pad size 16 square inches or less (A6402) provided on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 13, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and 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. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the T6 and T7 kyphoplasty (22513). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the medical record clearly documents that this enrollee does not meet 
evidence-based criteria. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the detailed documentation is not evident regarding acute and/or subacute fractures at T6 and 
T7. Additionally, there is no documentation of a progression of the body height loss, greater than 25 percent 
vertebral body height loss, kyphotic deformity, or a severe impact on daily activities. Moreover, there is 
computed tomography corroboration of retropulsion of T7 and other plausible causes of pain. Therefore, the 
enrollee does not meet the criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the T6 and T7 kyphoplasty (22513).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 09, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. 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 laboratory services 
provided on May 09, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve backrest options 8 deg with push handles. 
 
You asked the Plan to pre-approve backrest options 8 deg with push handles. You say that the requested items 
will allow for energy conservation during mobility related activities of daily living. The Plan denied your 
request. The Plan says the requested item 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 backrest options 8 deg with push handles.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D7956). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 
guided tissue regeneration (D7956).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you say that you disagree with the denial 
for the admission to a LTACH. The Plan denied your request. The Plan says these services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting. Documentation 
does not support that LTACH services are medically appropriate at this time. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical dressings provided during an outpatient hospital 
encounter on May 3, 2023, billed with code A6209. 
 
You asked the Plan to pay for the surgical dressings. You say that this claim should be paid as billed.  The Plan 
denied your request. The Plan says all codes were approved for payment except for A6209. A modifier is 
required to pay this code.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code A6209 has a status indicator of N in the Outpatient Prospective Payment System (OPPS). This means that 
payment for this item is always packaged in payment for other services. No separate payment can be made for 
this code. Based on this information, we decided that Medicare rules for coverage of the surgical dressings 
have not been met. Therefore, we decided that the Plan does not have to pay for the surgical dressings provided 
during an outpatient hospital encounter on May 3, 2023, billed with code A6209.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87502 billed for date of service November 
29, 2022. 
 
You asked the Plan to pay for procedure code 87502. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 87502 is bundled into payment for code 
87633. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 87502 
is a column II code to column I code 87633. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 87502 billed for date of service November 29, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 (prothrombin, coagulation factor II) (e.g., hereditary 
hypercoagulability) gene analysis, 20210G>A variant, and F5 (coagulation factor V) (e.g., hereditary 
hypercoagulability) gene analysis, Leiden variant. You asked the Plan to pre-approve F2 (prothrombin, coagulation factor II) (e.g., hereditary hypercoagulability) 
gene analysis, 20210G>A variant, and F5 (coagulation factor V) (e.g., hereditary hypercoagulability) gene 
analysis, Leiden variant. You say that the requested genetic testing is medically necessary based on family 
health history. The Plan denied your request. The Plan says requested genetic testing does not meet the 
Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that the requested genetic testing 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 pre-approve F2 (prothrombin, coagulation factor II) 
(e.g., hereditary hypercoagulability) gene analysis, 20210G>A variant, and F5 (coagulation factor V) (e.g., 
hereditary hypercoagulability) gene analysis, Leiden variant. Our reviewer says that the requested genetic 
testing is not considered medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has been diagnosed with a splenic infarct. It is noted that the family history is notable for unprovoked 
deep vein thrombosis (DVT) in the enrollees mother and the enrollees maternal grandmother. Genetic testing 
for these genes for all risk factors, signs, symptoms, diseases, or conditions, including cardiovascular risk 
assessment, are non-covered except for pregnant patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of F2 (prothrombin, coagulation factor II) (e.g., hereditary hypercoagulability) 
gene analysis, 20210G>A variant, and F5 (coagulation factor V) (e.g., hereditary hypercoagulability) gene 
analysis, Leiden variant have not been met. Therefore, we decided that the Plan does not have to pre-approve 
F2 (prothrombin, coagulation factor II) (e.g., hereditary hypercoagulability) gene analysis, 20210G>A variant, 
and F5 (coagulation factor V) (e.g., hereditary hypercoagulability) gene analysis, Leiden variant.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a footplate connector (K0108) and footplate width extensions 
(K0108 x2). 
 
You asked the Plan to pre-approve a footplate connector and footplate width extensions. You say that the 
enrollee's mobility is limited by muscle weakness and range of motion deficits. The Plan denied your request. 
The Plan says that it is not shown that the standard footplate hardware and standard width footplate are unable 
to meet the enrollee's needs. 
 
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 a footplate connector and footplate 
width extensions. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee is functionally non-ambulatory and requires a 
power wheelchair for mobility and performing their basic daily activities. This includes a group 2 power 
wheelchair with power tilt and power elevation leg rests for pressure relief and positioning. Our reviewer found 
that given the dimensions of the enrollee's lower extremities, they require the foot plate connector and 
extension to allow for proper positioning of their lower limbs. Our physician reviewer also found that standard 
hardware will not allow for this. 
 
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 footplate connector and footplate width extensions have been met. Therefore, 
we decided that the Plan has to pre-approve a footplate connector (K0108) and footplate width extensions 
(K0108 x2).  
 
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 pay for a detailed and extensive oral evaluation (D0160) provided on 
May 12, 2023. 
 
You asked the Plan to pay for D0160. You say that you would like these charges to be based on in-network 
rates. The Plan denied your request. The Plan says the denied dental service is not a covered benefit. 
 
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 detailed 
and extensive oral evaluation (D0160) provided on May 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the physical or manipulative therapy 
performed for maintenance rather than restoration (S8990) from February 7, 2022, through June 26, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services are 
not payable as the claim was submitted untimely.  
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until June 27, 2023. This means that more than 
one calendar year from the dates of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to issue reimbursement for the physical or manipulative therapy performed for maintenance 
rather than restoration (S8990) from February 7, 2022, through June 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341 x 2) provided 
on May 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 Plan's 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 September 13, 2022. 
Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing (D4341 x 2) 
provided on May 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upright walker. 
 
You asked the Plan to pre-approve the requested walker. You say that you are in pain. The Plan denied your 
request. The Plan says the request does not meet the criteria. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
 The file shows that you have a four-wheeled walker with a seat. Your current walker serves the same purpose 
as the requested walker. The medical records do not show that you have a severe neurologic disorder that 
restricts the use of one hand. Based on this information, we decided that the Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pre-approve an upright walker.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel testing coded as 87481, 87150, and 
87798 provided January 19, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you have attached the required medical 
records to prove the services rendered were medically necessary. The Plan denied your request. The Plan says 
the PCR testing is considered unproven and 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 looked at the file and Medicare rules. The standard of care for the evaluation of urinary incontinence is 
urinalysis with urine culture and sensitivity. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the Urine PCR panel testing coded as 87481, 87150, and 87798 provided January 19, 2023.