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

 
We decided that the Plan has to pay for procedure code E0570 provided on July 14, 2023. 
 
You asked the Plan to pay for procedure code E0570. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that prior authorization was not obtained to 
provide out-of-network (OON) care. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan's contract shows that the enrollee has out-of-network 
benefits. The Plan contract says as a member of the Plan, enrollees can choose to receive care from out-of-
network providers and enrollees do not need to get a referral or prior authorization when getting care from an 
out-of-network provider.  The Plan has provided no other rationale for the denial of payment for the services 
besides network status and prior authorization. As the Plan's contract clearly says the enrollee has out-of-
network benefits that do not require a referral or prior authorization, we find that the Plan has not adequately 
supported their decision. Therefore, we decided that the Plan has to pay for procedure code E0570 provided on 
July 14, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services billed with code 99308 for August 10, 
2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the 
same specialty must bill and be paid as though they were a single physician.  
 
We looked at the file and Medicare rules. The file shows that code 99308 was previously billed by a physician 
in the same group practice for the same date of service; therefore, the second billing of code 99308 cannot be separately paid. Therefore, we decided that the Plan does not have to pay for the physician services billed with 
code 99308 for August 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 10, 2023, to June 11, 
2023, billed with procedure code 93970. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the diagnosis is inconsistent with the procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that it is not appropriate to bill Medicare for services 
that are not covered as if they are covered. 
 
We looked at the file and Medicare rules. This claim has not been reported with a diagnosis code from the list 
of codes that support medical necessity. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. Therefore, we decided that the Plan does not have to pay for practitioner services provided on June 10, 2023, to June 11, 2023, billed with procedure code 
93970.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the breast cancer 1 and 2 (BRCA1, BRCA2) genetic 
testing (81162). 
 
You asked the Plan to pre-approve the genetic testing. You say that your doctor recommended that you get 
tested since the gene from your mother and sister was tested for the BRCA and found positive. The Plan denied 
your request. The Plan says the Medicare criteria for coverage have not been met. 
 
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 records show that the enrollee does not have a personal history 
of any type of cancer. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing have not been met. Therefore, we decided that the Plan does not have to pre-approve the breast cancer 1 
and 2 (BRCA1, BRCA2) genetic testing (81162).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 14, 2023. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says a corrected claim is needed in order for services to 
be reviewed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 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 the practitioner services provided have 
been met. Specifically, a corrected claim must be submitted in order to reprocess this claim. Therefore, we 
decided that the Plan does not have to pay for practitioner services provided on March 14, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Botox. 
 You asked the Plan to pre-approve Botox. You say that Botox is a medical necessity for the enrollee. The Plan 
denied your request. The Plan says step-therapy rules for coverage of Botox 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 Botox. Our reviewer says that treatment 
with Botox is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan 
requires a trial of drugs Dysport and Xeomin before they will approve the requested drug. In this case, the 
enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the 
Plans required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Botox.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the brain (70553) 
provided on May 30, 2023, to June 1, 2023. 
 
You asked the Plan to pay for the MRI. You say that the service was billed correctly and should be paid. The 
Plan denied your request. The Plan says CPT code 70553 cannot be billed separately because it is packaged 
into payment for CPT code 99291. 
 
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 70553 is magnetic resonance (eg, proton) imaging, brain 
(including brain stem); without contrast material, followed by contrast material(s) and further sequences. 
 
We find that CPT code 70553 is not supported in the medical record. Specifically, code 70553 has an indicator 
of Q3 status in the Outpatient Prospective Payment System (OPPS). Q3 codes are packaged and are not 
separately paid when billed with another code with an OPPS indicator of S, T, or V. In this case, code 99291 
was billed and paid on the same date of service and has an S indicator. Therefore, code 70553, and 99291 are 
not separately paid. Based on this information, we decided that Medicare rules for coverage of the MRI have 
not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging 
(MRI) of the brain (70553) provided on May 30, 2023, to June 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cologuard testing (81528). 
 
You asked the Plan to pre-approve the Cologuard testing. You say that you would like this test covered. The 
Plan denied your request. The Plan says criteria are not met for this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that the Cologuard test is covered for Medicare 
beneficiaries who are 50-85 years old.  
 
We looked at the file and Medicare rules. In this case, the record shows that you are greater than 85 years of 
age. Based on this information, we decided that Medicare rules for coverage of the Cologuard testing have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the Cologuard testing (81528).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702).  
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee has been referred by their 
family practice physician for myoelectric orthotic restoration, using the MyoPro Motion G. The Plan denied 
your request. The Plan says this is considered experimental and investigational due to insufficient evidence of 
safety and efficacy. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G orthotic device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options and accessories (E0955, E0956, E1007, E1012, E1028, E2300, E2311, E2313, E2361, E2377, E2620, 
E2622, K0040, K0861). 
 
You asked the Plan to pre-approve the power wheelchair and accessories. You say that this type of wheelchair 
is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with multiple power 
options is covered when there is a medical need for a wheelchair mounted ventilator or for power tilt AND 
power recline features. 
 
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 power wheelchair and accessories. 
Our reviewer says that the requested power wheelchair is not medically necessary. Our physician reviewer 
found 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. The enrollee does not use a ventilator or require power 
tilt or recline. Since the base wheelchair is non-covered, the requested accessories are also non-covered. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power options and 
accessories (E0955, E0956, E1007, E1012, E1028, E2300, E2311, E2313, E2361, E2377, E2620, E2622, 
K0040, K0861).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says the Intracept procedure is 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 the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is no magnetic resonance imaging (MRI) showing only Modic changes 
without facet degenerative joint disease or stenosis. The cause of pain is not clear. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transfer bench, heavy duty, for tub or toilet with or 
without commode opening (E0248). 
 
You asked the Plan to pre-approve a transfer bench. You say that the medical records provided will show proof 
of medical necessity. The Plan denied your request. The Plan says the enrollee already has received similar 
equipment in 2023 and the one requested now is not covered. 
 
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 rules say that for equipment to be covered, it must primarily serve a medical 
purpose.   
 The file shows that you have a bariatric bath chair. The bariatric bath chair serves the same purpose as a 
transfer bench. The item also 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 transfer bench, heavy duty, for tub or toilet with or without commode 
opening (E0248).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that the medical records provided will 
show proof of medical necessity. The Plan denied your request. The Plan says this item is not a Medicare 
covered benefit. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 29, 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 August 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical 
therapy services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) coded E0675 and 
half leg appliance coded E0673 billed for July 25, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Given that the E0675 PCD is not covered, the half leg 
appliance billed with code E0673 is also not covered. Therefore, we decided that the Plan does not have to pay 
for the pneumatic compression device (PCD) coded E0675 and half leg appliance coded E0673 billed for July 
25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skin barrier wipes (A6250, E1399). 
 
You asked the Plan to pre-approve the skin barrier wipes. You say that you have to continuously wear a 
condom catheter and have to use skin barrier wipes so that the catheter can stick and stay on. You I would like 
to continue to get the skin barrier wipes covered. The Plan denied your request. The Plan says this item is not a 
Medicare covered benefit. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the skin barrier wipes have not been met. Therefore, we decided that the Plan does not have to pre-
approve the skin barrier wipes (A6250, E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care visit (99309) provided on 
October 26, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the nursing facility visit. You say that this is a skilled nursing home patient, and 
the doctor is the assigned attending physician at the facility. Authorization is not required.  The Plan denied 
your request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care visit (99309) 
provided on October 26, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and a prefabricated post and core 
build-up (D2954) for tooth #8. 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to approve this 
dental work. The Plan denied your request. The Plan says your annual dental allowance amount 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 annual dental allowance amount was exhausted on date of service September 27, 2023. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) and a prefabricated post and core 
build-up (D2954) for tooth #8.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0013M) provided February 3, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0013M) provided February 3, 2023.