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

 
We decided that the Plan does not have to pre-approve an expandable controller harness (E2313) and an 
electronic connector to 2 power options (E2311). 
 
You asked the Plan to pre-approve the expandable controller harness and the electronic connector to 2 power 
options. You say that the expendable electronics are required to operate the wheelchair with multiple power 
functions. You say that you badly need the items in dispute. The Plan denied your request. The Plan says the 
upgraded electronics which remain in dispute are 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 expandable controller harness and 
the electronic connector to 2 power options. Our reviewer says that the requested items are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee was approved for a 
Group 3 power wheelchair with tilt and elevating leg rests. The enrollee is noted to have upper extremity 
weakness, but is independent in toileting and cooking. The documentation does not reveal that the enrollee 
requires the other types of proportional input devices or non-proportional input devices. The enrollee does not 
need to operate 3 or more power seating actuators through the drive control, a separate display, or an attendant 
control. 
 
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 expandable controller harness and the electronic connector to 2 power 
options have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable 
controller harness (E2313) and an electronic connector to 2 power options (E2311).
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 the enrollee needs physician and nursing 
services around the clock. The Plan denied your request. The Plan says the enrollee does not have a reasonable 
expectation for improvement in the LTACH setting. 
 
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 review indicates that the enrollee still requires acute hospital level of care 
services and is receiving appropriate care at the present acute care hospital. There are no services available at 
the LTACH that the enrollee requires that are not available at the health care setting being offered by the health 
plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis 
and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on May 15, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 15, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on May 
15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says Retacrit is not covered under the enrollee's Medicare Part B 
benefit when dispensed to the enrollee by a pharmacy. 
 
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 Retacrit.  
 
Benefits for Retacrit 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: 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 updated notes and documentation 
support an LTACH placement. The Plan denied your request. The Plan says it is not medically necessary to be 
in an LTACH. 
 
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 does not require services at the LTACH that are not available at the 
acute care hospital where he is currently receiving care. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 24, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
physician?s services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on June 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder orthosis provided on May 14, 2020. 
 
You asked the Plan to pay for the shoulder orthosis (L3660). You say that you are not part of the hospital and 
are unable to obtain pre-authorization at the time of service. The Plan denied your request. The Plan says you 
did not request prior authorization for the orthosis. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The Plan has network 
providers available who can provide the item at issue in this appeal. The Plan did not pre-approve the item at 
issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the 
Plan does not have to pay for the shoulder orthosis provided on May 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assistive 
device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not considered a covered item. 
 
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 device. Our reviewer says that the 
requested device is not considered medically reasonable and necessary in this case. Our physician reviewer 
found at this time the requested robotic orthosis is not proven to be more beneficial for treatment of the 
enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy. The 
requested device is not the standard of care for hemiparesis after a stroke over standard treatment including 
treatment such as physical and occupational therapy, strengthening exercises, constraint induced movement 
therapy, Botox injections for spasticity, etc. The American Heart Association/American Stroke Association 
discusses electromyographic biofeedback as used in the Myopro however there is little evidence in the 
literature on how well this device would restore muscle strength post stroke. The requested device is not 
reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a 
malformed body member. A review of the literature reveals additional controlled studies of the MyoPro 
Orthosis for upper extremity paralysis after stroke are needed with larger patient groups, consistent 
improvements of relevant outcome functional measures,  and long term follow up. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a powered upper extremity range of motion assistive device for the enrollee.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a low dose CT scan (LDCT). 
 
You asked the Plan to pre-approve the LDCT. You say that the records provided support the need for a LDCT. 
The Plan denied your request. The Plan says that the records show that a chest CT is supported. The Plan says 
that the clinical information provided describes a request for a screening study and, therefore, the request is not 
indicated at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 the LDCT. Our reviewer says that the 
criteria for coverage have been met. Our physician reviewer found an LDCT offers adequate screening with 
less exposure to potentially harmful radiation. Our physician reviewer found that it is in the enrollee's best 
interests to perform a screening LDCT, and this service is indicated. 
   
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 LDCT have been met. Therefore, we decided that the Plan has to pre-
approve a low dose CT scan (LDCT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a pneumatic compression device (E0652). 
 
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the 
device. The Plan denied your request. The Plan says the documentation failed to prove that sufficient evidence 
of four-week trial of conservative therapy. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device 
(E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) 
provided to the enrollee on June 17, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollees condition. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a 
covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary 
and conducted a face-to-face assessment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the durable medical equipment have not been met. Specifically, medical records do not support a 
prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an 
appropriate use of telehealth. The submitted consultation notes do not support that a physical examination was 
performed. The information submitted does not confirm that Medicare coverage criteria have been met. 
Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, 
L2397) provided to the enrollee on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve the Vertiflex device. You say that the enrollee is in severe pain that 
interferes with his function abilities and quality of life. The Plan denied your request. The Plan says the 
guidelines 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 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 Vertiflex device. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the requested device is 
considered experimental and investigational. Our physician reviewer found that more research is needed to 
show the safety and efficacy of the requested device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastroenterology referral. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has been no initial evaluation to establish a clinical suspicion for pancreatitis, 
diverticulosis, functional abdominal pain, gastroparesis, IBD, IBS, or peptic ulcer disease. 
 
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 referral. Our reviewer says that the 
requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the case file does not contain a physical exam or the results of any imaging. The documentation is 
insufficient to support that referral to a gastroenterologist is medically reasonable and necessary for the enrollee 
in this case. 
 
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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a gastroenterology referral.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular stimulator provided on March 9, 2020, 
and April 9, 2020. 
 
You asked the Plan to pay for the neuromuscular stimulator. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the item rendered is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the neuromuscular 
stimulator provided on March 9, 2020, and April 9, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued SNF services. You say that this care is medically necessary. The 
Plan denied your request. The Plan says Medicare criteria for continued care are not met.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 continued SNF services. Our reviewer says that daily skilled services are not necessary. Our 
physician reviewer found the medical records do not show that you require ongoing skilled nursing services.  
You do not require complex wound care or other ongoing SNF level needs. Your functional level does not 
require ongoing skilled therapy services. No services are required daily at a SNF level of care. Medicare 
coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of continued SNF services have not been met.  
Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) 
services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided to the enrollee from December 25, 2019 to 
December 30, 2019 and billed under code S9501. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says code S9501 has a status code indicator of  which is not payable on Medicare claims.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the code billed has a status code 
indicator of which that does not allow payment on Medicare claims. Therefore, we decided that the Plan 
does not have to pay for services provided to the enrollee from December 25, 2019 to December 30, 2019 and 
billed under code S9501.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Benlysta. 
 
You asked the Plan to pre-approve Benlysta. You say that this is medically necessary. The Plan denied your 
request. The Plan says this drug is not supported for patients with severe lupus nephritis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Benlysta. Our reviewer says that the 
criteria for coverage of Benlysta have not been met. Our physician reviewer found ased on the medical records 
provided there is no documentation that supports that the Benlysta is medically reasonable and necessary for 
the patient as Benlysta is not recommended in patients with severe active lupus nephritis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Benlysta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Benlysta.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the orthotics provided on June 15, 2020. 
 
You asked the Plan to waive the coinsurance for the orthotics. You say that the coinsurance is an unexpected 
expense. The Plan denied your request. The Plan says you were charged this coinsurance correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Prosthetic devices and related supplies.  
 
You have been asked to pay 20% coinsurance for the orthotics. The orthotics fall within the Prosthetic devices 
and related supplies benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the orthotics 
provided on June 15, 2020.