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

 
We decided that the Plan does not have to pre-approve an osteogenic stimulator to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve an osteogenic stimulator. You say that you feel the enrollee needs this due 
to the enrollee's high risk spinal fusion surgery extending from the T11 vertebrae to 
the L2 vertebrae, increased risk of non-fusion due to high BMI, and need for assistance during 6-9 months of 
recovery via ActaStim-Ss integrated remote patient monitoring. The Plan denied your request. The Plan says 
the requested item can be provided by a network provider. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an osteogenic stimulator 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 provide reimbursement for diabetic supplies provided on December 
1, 2022, to December 31, 2022. 
 
You asked the Plan to provide reimbursement for diabetic supplies. You say that you do not agree with the 
denial for reimbursement. The Plan denied your request. The Plan says they are unable to reimburse for 
medical supplies/services obtained from a non-licensed DME provider. 
 
The Plan must follow Medicare rules. Medicare rules say that health plan must disclose to its enrollees in clear, 
accurate terms all cost sharing information such as copayments, coinsurance, and deductibles. You must obtain 
DME & related supplies from a licensed DME provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of diabetic supplies have not been met. Therefore, we decided that the Plan does not have to provide 
reimbursement for diabetic supplies provided on December 1, 2022, to December 31, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the behavioral counseling for obesity billed with code G0447 
for October 26, 2022. 
 
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 criteria for coverage are not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers intensive behavioral therapy for 
obesity, defined as a body mass index (BMI) = 30 kg/m2. 
 
We looked at the file and Medicare rules. The file shows that the enrollee had a BMI of 26.29, which does not 
meet the criteria for coverage. 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 pay for the behavioral 
counseling for obesity billed with code G0447 for October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left heart catheterization. 
 
You asked the Plan to pre-approve a left heart catheterization. You say that the requested left heart 
catheterization is medically necessary.  The Plan denied your request. The Plan says the requested left heart 
catheterization 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 a left heart catheterization. Our 
reviewer says that the requested left heart catheterization is not medically necessary.  Our physician reviewer 
found the enrollee has no cardiac symptoms and there has been no stress test performed. The medical records 
provided do not support the rationale for this invasive imaging study. Guidelines do not support a need for 
cardiac catheterization in this setting. As a result, at this time cardiac catheterization would not be considered medically appropriate and necessary in this enrollees clinical management. 
 
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 left heart catheterization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a left heart catheterization.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power wheelchair. 
 
You asked the Plan to pre-approve a replacement power wheelchair. You say that you feel you were not given 
proper time to collect information that was needed before the authorization was denied for a new wheelchair. 
You also say that you had to cancel doctor appointments because you do not have a wheelchair. The Plan 
denied your request. The Plan says the records do not show that your current power wheelchair has reached its 
expected lifetime or that it is no longer in working order.  
 
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 also say that a PWC is covered when all the criteria listed in the Medicare 
rules section 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 a replacement power wheelchair. Our reviewer says 
that the requested power wheelchair is not medically necessary. Our physician reviewer found that the 
documentation available for review does not specifically indicate the reason for a replacement power 
wheelchair. There is no clear documentation that indicates how old your current wheelchair is and if it is in 
disrepair. 
 
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 replacement power wheelchair have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a replacement power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88374 billed for date of service January 17, 
2023.   
You asked the Plan to pay for procedure code 88374. You say that you disagree with the denial. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88374 is 5. The MAI value for this code is 3. You billed 8 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88374 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88374 billed for date of service January 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anchoring of biceps tendon (23430). 
 
You asked the Plan to pre-approve anchoring of biceps tendon. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria 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 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 anchoring of biceps tendon. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no clinical documentation of a problem with the bicep tendon or 
muscle. More info is needed in this patient with total shoulder replacement (TSR). 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of anchoring of biceps tendon have not been met. Therefore, we decided that the 
Plan does not have to pre-approve anchoring of biceps tendon (23430).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided 
on January 10, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the topical 
application of fluoride varnish (D1206) provided on January 10, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on November 14, 2022. 
 
You asked the Plan to pay for nursing facility 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 nursing facility care 
provided on November 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigationper quadrant (D4921 x 4) provided on 
October 20, 2022. 
 
You asked the Plan to pay 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 these services are 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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival 
irrigationper quadrant (D4921 x 4) provided on October 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on February 17, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
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 item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on February 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on December 6, 2022, billed with codes 
87798 and 87481. 
 
You asked the Plan to pay for the testing. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services are not payable as billed.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT codes 87798 and 87481 are not payable as billed. Specifically, the standard of care for the 
evaluation of urinary incontinence is urinalysis with urine culture and sensitivity. The PCR panel testing is 
considered excessive testing and not covered in this instance. 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 testing provided on December 6, 2022, billed with codes 87798 and 87481.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 provided on February 8, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for procedure code 99214 provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide OON care. 
 
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 procedure code 99214 provided on February 8, 
2023, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs several hours a day of 
wound care and pain medication along with antibiotics. The Plan denied your request. The Plan says that the 
admission to a LTACH is 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 that the enrollee appears to be improving and should only require short-term 
additional acute care hospital services that can safely be provided at the current facility until they are more  
 appropriate for a lower level of care soon. The enrollee does not require services at the LTACH that are not 
already available at the current facility. 
 
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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for diabetic supplies provided on March 21, 
2023. 
 
You asked the Plan to waive the coinsurance for diabetic supplies. You say that you do not agree with 
copayment for the diabetic supplies. 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 diabetes self-management training, diabetic services and supplies. 
 
You have been asked to pay 20% coinsurance for diabetic supplies. This item/service falls within the diabetes 
self-management training, diabetic 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 coinsurance for diabetic supplies provided on March 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump billed with code 
E0217 for July 20, 2022, to August 9, 2022. 
 
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. The rules say that a water circulating heat pad with pump (E0217) is 
denied as not medically necessary. 
 
We looked at the file and Medicare rules. The item at issue is a water circulating heat pad with pump billed 
with code E0217. This code is denied by Medicare as not medically necessary. Therefore, we decided that the 
Plan does not have to pay for the water circulating heat pad with pump billed with code E0217 for July 20, 
2022, to August 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on June 
24, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service was 
exhausted retroactively due to the claim for date of service January 24, 2023 processing first. 
 
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 24, 2023. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on June 24, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on March 03, 2023. 
 
You asked the Plan to pay for physical therapy. 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 physical therapy 
provided on March 03, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve speech therapy services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve speech therapy services. You say that the enrollee would like to continue all 
therapies at the same location. The Plan denied your request. The Plan says the requested services can be 
provided by a network provider. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
speech therapy services to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on February 16, 2023. 
 
You asked the Plan to pay for nursing facility 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 nursing facility care 
provided on February 16, 2023.