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

We decided that the Plan does not have to pre-approve a Drive Medical Nitro Euro rollator walker. 
 
You asked the Plan to pre-approve a Drive Medical Nitro Euro rollator walker. You say that this is medically 
necessary for you. The Plan denied your request. The Plan says that this is not a covered benefit. 
 
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 Drive Medical Nitro Euro rollator 
walker. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. There is no evidence that you have a personal mobility deficit that impairs participation 
in MRADLs in the home.  
 
An August 26, 2020 progress note indicates on exam no back pain, muscle pain, muscle cramps, muscle 
weakness, numbness, tingling, weakness, vertigo or fatigue. There is no detailed neuromuscular exam noted on 
this progress note. There is no evidence that your mobility deficit is unable to be helped by your current walker 
and that you require a Drive Medical Nitro Euro Rollator Walker which has convenience features and seat 
attachment. Our physician reviewer found that your condition does not meet Medicare criteria for a Drive 
Medical Nitro Euro rollator walker. 
 
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 Drive Medical Nitro Euro rollator walker have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Drive Medical Nitro Euro rollator walker.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic procedure, 1 or more areas, each 15 minutes; 
therapeutic exercises to develop strength and endurance, range of motion and flexibility (CPT Code 97110), 
CMT; extraspinal, 1 or more regions (98943), office or other outpatient visit for the evaluation and 
management of an established patient, typically, 15 minutes are spent face-to-face with the patient and/or 
family (99213) and electrical stimulation (unattended), to one or more areas for indication(s) other than wound 
care, as part of a therapy plan of care (G0283) provided on April 3, 2020. 
 
You asked the Plan to pay for the services. You say that you are appealing for reconsideration of the denied 
charges. The Plan denied your request. The Plan says the services are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises 
to develop strength and endurance, range of motion and flexibility (CPT Code 97110), CMT; extraspinal, 1 or 
more regions (98943), office or other outpatient visit for the evaluation and management of an established 
patient, typically, 15 minutes are spent face-to-face with the patient and/or family (99213) and electrical 
stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan 
of care (G0283) provided on April 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the brand specific power mobility device. 
 
You asked the Plan to pre-approve a power mobility device (K0899). You say that the requested scooter is the 
only scooter that would medically assist your need. The Plan denied your request. The Plan says the supplier no 
longer manufactures the requested scooter. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that you cannot safely operate the PMD being requested due to trunk instability. The file also 
shows your residence would not support the use of a scooter. The requested scooter has been discontinued for 
several years and is not available. This means that Medicare rules for coverage of the requested scooter have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the requested power mobility 
device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture and a complete 
mandibular denture. 
 
You asked the Plan to pre-approve the complete maxillary denture and complete mandibular denture. The Plan 
denied your request. The Plan says these services are allowed one time every 60 months. The Plan also says 
that you received these services less than 60 months ago. 
 
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, dentures are limited to one set every 5 
years. The record shows that you received a complete maxillary denture and a complete mandibular denture on 
April 21, 2016 and your dentures benefit has been exhausted. Therefore, we decided that the Plan does not have 
to pre-approve a complete maxillary denture and a complete mandibular denture.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87486, 87498, 87541, 87581, 
87633, 87635, 87640 and 87798 provided on May 7, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 find that CPT codes 87486, 87498, 87541, 87581, 87633, 87635, 87640 and 87798 are not supported in the 
medical record. Specifically, laboratory results have not been submitted for the billed date of service. The 
documentation does not support an established relationship between the enrollee and the ordering physician. 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87486, 
87498, 87541, 87581, 87633, 87635, 87640 and 87798 provided on May 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot stabilizers and a special wheelchair back for a 
power wheelchair (PWC). 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that there is no separate payment for mounting hardware 
for a seat or back cushion and that mounting hardware is represented by code E0954. 
 
We looked at the file and Medicare rules. The file shows that a special wheelchair back is requested with code 
K0108. The cushion is already approved under code E2607. The foot stabilizers are requested with code K0108 
but cannot be approved with this code and should be requested as code E0954. 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 foot stabilizers and a special wheelchair back for a power wheelchair 
(PWC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not considered a covered benefit. 
 
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 scooter. Our reviewer says that the 
requested scooter is not considered medically reasonable and necessary in this case. Our physician reviewer 
found no records were provided which documented your functional status or ambulatory dysfunction. A knee 
scooter is not considered a covered benefit by Medicare. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee scooter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's complex medical needs are being met in the 
current acute setting at this time. 
 
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. The patient 
appears to be improving, but requires additional acute care services to further stabilize which is likely to take 
less than 25 additional days based on recent notes. The patient does not require services at the LTACH that are 
not already available at the current facility. Transfer to a lower level of care may be considered with further 
improvement. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 
LTACH services. 
 
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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Ki-67 genetic testing provided on February 3, 2020. 
 
You asked the Plan to pay for genetic test. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because this test is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Ki-67 genetic testing is not covered by Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic test have not been met. Therefore, we decided that the Plan does not have to pay for Ki-67 
genetic testing provided on February 3, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the continuous glucose monitor supply allowance (K0553) provided on 
March 2, 2020. 
 
You asked the Plan to pay for the continuous glucose monitor supply allowance. You say that you would like 
reconsideration because the provider signed the medical records on September 20, 2019. The Plan denied your 
request. The Plan says that the DME form is over 6 months old and there was no member signature on the 
delivery ticket. 
 
The Plan must follow Medicare rules. Medicare rules say that the supplier for all Durable Medical Equipment, 
Prosthetic, and Orthotic Supplies (DMEPOS) must have an order from the treating physician before giving any 
DMEPOS item to an enrollee and must keep the order and proof of delivery documentation on file. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the continuous glucose monitor supply allowance have been met. Specifically, the record indicates 
that the member had a face-to-face encounter with their physician to discuss these supplies within 6 months of 
this order. Additionally, the member's signature is not a required element when a delivery service is utilized. 
Therefore, we decided that the Plan has to pay for the continuous glucose monitor supply allowance (K0553) 
provided on March 2, 2020.  
 
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 pre-approve a custom fabricated abutment (D6057) and abutment 
supported porcelain/ceramic crown (D6058). 
 
You asked the Plan to pre-approve the custom fabricated abutment and abutment supported crown. You say 
that the Plan initially told you that these services would be covered, but then told you they would not cover it. 
You also say that you are unable to afford these procedures on your own. The Plan denied your request. The 
Plan says these services are not covered under your benefit package. 
 
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 a 
custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion device (E0936). 
 
You asked the Plan to pre-approve a continuous passive motion device. You say that you need this to help your 
hand recover. The Plan denied your request. The Plan says this is not covered for your condition. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-
approve a continuous passive motion device (E0936).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature for a power wheelchair. 
 
You asked the Plan to pre-approve power seat elevation feature. You say that this feature is necessary for the 
enrollee and without it her quality of life would be diminished considerably. The Plan denied your request. The 
Plan says the denial of authorization for this device is correct, because this power seat elevation feature is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is not covered. 
 
We looked at the file and Medicare rules. This feature is not covered by Medicare. Based on this information, 
we decided that Medicare rules for coverage of power seat elevation feature have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation feature for a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for other chiropractor services provided from April 22, 2019 
through June 24, 2019. 
 
You asked the Plan to pay for other chiropractor services. You say that you are appealing for reconsideration of 
the denied charges. The Plan denied your request. The Plan says the services are not covered by Medicare or 
the Plan. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for other chiropractor services provided from April 22, 2019 through June 24, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel Sureclick injections. 
 
You asked the Plan to pre-approve Enbrel Sureclick injections. You say that the medication is necessary. The 
Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a 
separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 
coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Enbrel Sureclick injections.  
 
Benefits for Enbrel Sureclick injections may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on June 18, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that when using 7th character ?S?, it is necessary to 
use both the injury code that precipitated the sequela and the code for the sequela itself. The ?S? is added only 
to the injury code, not the sequela code. 
 
We looked at the file and Medicare rules. A sequela (7th character "S") code cannot be listed as the primary, 
first listed or principal diagnosis on a claim. Coding of a sequela requires reporting of the condition or nature of 
the sequela sequenced first, followed by the sequela. 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 
services provided on June 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no need for this level of care. 
 
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short term acute 
care hospitals. In this case, ongoing care needs include oral vancomycin, surveillance laboratory studies, and 
therapy services. The documentation does not support that the enrollee in this case requires services at the 
LTACH that are not available at the acute care hospital where he is currently receiving care. There are no 
required medical services identified that are available at the LTACH, that are not available at the current health 
care setting being offered by the health plan. Consequently, the requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file 
and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-
approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and 
necessary based on Medicare guidelines. Our physician reviewer found the complexity of the nursing, medical 
and rehabilitation needs do not currently require an interdisciplinary approach to rehabilitation care in an IRF.  
The medical status does not currently require intensive physician and nursing oversight only in an IRF as he 
continues to require acute hospital management documentation indicates a plan for a repair of an abdominal 
aortic aneurysm surgery. The documentation does not reveal outcome of this surgery or indications that the 
enrollee will be able to participate in an intensive rehabilitation therapy program provided in an IRF. We 
looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.