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

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on 
February 14, 2020. 
 
You asked the Plan to pay for the orthosis. 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 
enrollee's 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. Therefore, we decided that the Plan does not have to pay for a 
lumbar-sacral orthosis (L0648) provided to the enrollee on February 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided to the enrollee on February 20, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the enrollee was not approved for inpatient level of care. 
 
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 pay for the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there was no documentation provided indicating the enrollee required or received any inpatient 
diagnostic studies or therapeutic interventions. The review has determined that given the procedure is not on 
the inpatient only list, based on the records provided, the enrollee both before and after the procedure did not 
require care at an acute inpatient level of care. The enrollee's care could have been appropriately provided at an 
observation level of service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services provided to the enrollee on February 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair. 
 
You asked the Plan to pre-approve a manual wheelchair. You say that this is medically necessary. The Plan 
denied your request. The Plan says the submitted records do not document the enrollee has a mobility 
limitation. 
 
The Plan follows Medicare rules. Medicare rules say that a manual wheelchair for use inside the home is 
covered when criteria A, B, C, D, and E listed above are met; and criterion F or G is met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a manual wheelchair. Our reviewer says 
that the records do not show that the requested wheelchair is medically necessary. Our physician reviewer 
found the documentation is not clear that the patient has an actual mobility limitation that interferes with her 
MRADLS. It appears that she has severe dementia which is interfering with her desire to ambulate and in 
interfering with MRADLs.The documentation is not clear that the mobility limitation cannot be sufficiently 
resolved by the use of an appropriately fitted cane or walker or that use of the wheelchair will significantly 
improve the ability to participate in MRADLS and she will use it on a regular basis. The documentation does 
not reveal that the patient has the cognitive capabilities to self propel a wheelchair. While the family may be 
willing to provide assist with the wheelchair it appears that the family is arranging 24 hour aid  to care for the 
patient therefore it is not clear that the aides are all  agreeable and able to provide assist with the wheelchair. 
 
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 manual wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a manual wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a repair of joint dislocation (28636) provided on November 
13, 2019. 
 
You asked the Plan to pay for a repair of joint dislocation. You say that this is shown in the records. The Plan 
denied your request. The Plan says this code is not documented. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our 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 pay for a repair of  joint dislocation. Our reviewer 
says that this code is not supported. Our physician reviewer found the submitted records do not include 
documentation that percutaneous skeletal fixation of metatarsophalangeal joint dislocation, with manipulation 
was performed. 
 
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 repair of  joint dislocation have not been met. Therefore, we decided that the 
Plan does not have to pay for a repair of  joint dislocation (28636) provided on November 13, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on September 16, 2019. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on September 16, 2019.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) of the thorax. 
 
You asked the Plan to pre-approve the CT scan. You say that the enrollee has had an x-ray and that the 
radiologist is still recommending a CT scan. The Plan denied your request. The Plan says that the requested 
imaging is not supported without results of a recent chest x-ray. The Plan says that the x-ray completed on 
August 20, 2020 provided no clinical findings. The Plan say that there are no findings of trial of conservative 
care, gastrointestinal or cardiac evaluation, and the criteria for coverage have not been met. 
 
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 CT scan. Our reviewer says that the 
requested CT scan is medically necessary. Our physician reviewer found the enrollee has tenderness and 
fullness over her clavicle. A plain x-ray showed no abnormality but noted that body habitus reduced the 
sensitivity of a plain x-ray as an imaging modality. A CT scan was recommended for evaluation of the 
presenting complaint. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve computed tomography (CT) of the thorax.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a urine collection system. 
 
You asked the Plan to pre-approve the urine collection system. You say that the system is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage is limited to one metal cup (A4327) per 
week or one pouch (A4328) per day.  
 
We looked at the file and Medicare rules. The system requested exceeds the cup or pouch that is covered by 
Medicare. Additionally, the requested supplier's website notes that they do not participate with commercial 
insurance, Medicare, or Medicaid. Based on this information, we decided that Medicare rules for coverage of 
the urine collection system have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a urine collection system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 19, 
2020 through February 20, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the patient's necessary hospital care (including 
earlier emergency department (ED) and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from February 19, 2020 through 
February 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair tiedown kit (K0108). 
 
You asked the Plan to pre-approve the power wheelchair tiedown kit. You say that the tiedown kit is medically 
necessary. The Plan denied your request. The Plan says this accessory is for use outside the home and is 
therefore non-covered. 
 
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 pre-approve a power wheelchair tiedown kit (K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration and inpatient hospital 
admission. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. 
The requested bone marrow aspiration is considered experimental in nature. More research is needed to show 
its safety and efficacy. The services are therefore not reasonable or medically necessary. Given that the bone 
marrow aspiration is not medically necessary, the inpatient admission is also not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. 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 bone marrow aspiration and inpatient hospital admission.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the periodontal scaling and root planing. We decided that the Plan 
does not have to pre-approve the pontic and retainer crown.  
 
You asked the Plan to pre-approve the periodontal scaling and root planing, pontic and retainer crown. You 
submitted x-rays to be reviewed to approve needed treatment. The Plan says that the criteria for coverage has 
not been met.  
We decided that the Plan has to pre-approve the periodontal scaling and root planing.  
 
Our physician reviewer says that the documentation supports the need for periodontal scaling and root planing 
due to the abnormal periodontal pockets and observable horizontal bone loss. Therefore, we decided that the 
Plan has to pre-approve the periodontal scaling and root planing, pontic and retainer crown.  
 
We also decided that the Plan does not have to pre-approve the pontic and retainer crown. 
 
Our physician reviewer says that before a fixed bridge can be placed to replace unerupted tooth #6, the tooth 
should be removed or guided into place. Therefore, we decided that the Plan does not have to pre-approve . 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Carboplatin. 
 
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 medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of head and 
neck cancer with metastases to the right lung and laryngeal cancer. Carboplatin does carry an off-label 
indication for the treatment of head and neck cancer but is usually used as first- or second-line therapy. This 
enrollee has received prior therapy with nivolumab with progression. Carboplatin is to be used in combination 
with fluorouracil and pembrolizumab which is not a standard regimen. In addition, once there is failure of one 
PD-L1 inhibitor, use of another with progression is not indicated. The service is not reasonable or medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. 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 Carboplatin.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(S9986). 
 
You asked the Plan to pre-approve special supplemental benefits for the chronically ill. You say that you were 
told by the sale representative that you would be eligible for these benefits. The Plan denied your request. The 
Plan says you do not have a qualifying diagnosis required to receive the benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that only medically necessary services are covered. 
The supplemental benefits at issue are not covered by Medicare. The plan's rules apply in this case.  
 
We looked at the file, the plan contract, and Medicare rules. The documentation provided shows that the 
enrollee does not have one of the chronic diagnoses required by the plan to receive the supplemental benefits at 
issue. Based on this information, we decided that Medicare rules for coverage of special supplemental benefits 
for the chronically ill have not been met. Therefore, we decided that the Plan does not have to pre-approve 
special supplemental benefits for the chronically ill (S9986).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you are only able to 
tolerate 10-20 minutes of minimal to moderate activity. 
 
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 physician reviewer found 
that you are generally medically stable, with no recent neurological or acute events, except a fracture with 
debility and chronic memory problems. There is no evidence that you require monitoring by an inpatient rehab 
physician three times per week, or a need for acute rehab nursing care. While you may benefit from continuing 
physical, occupational, and speech therapy, there is no evidence of need for an intensive therapy program with 
therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 
care. Therefore, an IRF admission is not necessary at your current level of function. 
 
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.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient require does not treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the record supports a need for physical and occupational therapy, there is no documented need 
for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) 
provided to the enrollee on February 15, 2020. 
 
You asked the Plan to pay for the orthosis. 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 
enrollee's condition. 
 
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 a knee orthosis with 
suspension sleeve (L1851, L2397) provided to the enrollee on February 15, 2020.