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

 
We decided that the Plan does not have to pre-approve a travel buggy electric wheelchair for the enrollee. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says this request is not considered reasonable or necessary. 
 
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.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found it is not clear 
from the documentation if the enrollee's personal mobility deficit impairs participation of MRADLs in the 
home. The deficit is currently helped by a walker. The documentation reveals no evidence of an in-home 
assessment to evaluate if the enrollee can safely maneuver the requested device in the home. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a travel buggy electric wheelchair for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new right prosthetic leg. 
 
You asked the Plan to pre-approve the prosthetic. You say that your current prosthetic is too heavy. The Plan 
denied your request. The Plan says the treating practitioner has not determined that the replacement device, or 
replacement part of such a device, is reasonable and 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 prosthetic. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not indicate that a new prosthetic leg is being furnished in a setting 
appropriate to your medical needs and condition. The new leg appears to exceed your need. The documentation 
indicates both your physician and physical therapy say that you do not need a new leg, and that your current leg 
can meet your needs, with adjustment from the vendor, and continued use for tolerance and physical therapy 
for strengthening. 
 
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 prosthetic have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a new right prosthetic leg.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayment for an MRI provided by a 
participating provider on May 14, 2020. 
 
You asked the Plan to waive the deductible and copayment for an MRI. You say that this is a large medical bill. 
You say that you do not agree with the amount applied. The Plan denied your request. The Plan says the correct 
deductible and copayment have been applied. 
 
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 a $300 
deductible and a $150 copayment for outpatient diagnostic tests/in-network/diagnostic radiology.  
 
You have been asked to pay a $300 deductible and a $92.23 copayment for an MRI. The total amount you are 
being asked to pay is $392.23 ($300 + $93.23 = $392.23). An MRI falls within the outpatient diagnostic 
tests/in-network/diagnostic radiology 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 deductible and 
copayment for an MRI provided by a participating provider on May 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve epidural steroid injection. You say that you are requesting an appeal for the 
denied Caudal epidural. Per the clinicals included the enrollee reports radicular pain into legs. Please approve. 
The Plan denied your request. The Plan says the clinical information provided does not describe the type of 
pain to meet the criteria, therefore the requested procedure is not indicated at this time. 
 
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 epidural steroid injection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Epidural steroid injections are supported for radiculopathy when there is pain which 
follows a dermatomal pattern that corresponds with the requested spinal levels. In this case, the clinical 
information provided does not describe this type of pain and, therefore, the requested procedure is not indicated 
at this time.  The review indicates that the medical records provided do not meet the requirements listed in the 
LCD for Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injection (ESI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 13, 2020 by an out of 
network (OON) provider. 
 
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 were rendered by an out-of-network provider without 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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on April 13, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the Puraply skin graft. 
 
You asked the Plan to pre-approve the graft. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the records indicate poor arterial perfusion, and it is unclear if the infection is 
cleared. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 graft. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested graft is medically reasonable and necessary because the wound can become infected 
between surgical procedures. 
 
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 graft have been met. Therefore, we decided that the Plan has to pre-approve 
the Puraply skin graft.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 24, 2020 by an 
out of network (OON) provider. 
 
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 rendered are not a covered benefit. 
 
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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 24, 
2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 22, 2020. 
 
You asked the Plan to pay for the laboratory 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 
laboratory 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 laboratory services provided on April 22, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy services provided from December 
23, 2019 to March 18, 2020. 
 
You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code S9328 is home infusion therapy, implanted pump pain 
management infusion; administrative services, professional pharmacy services, care coordination, and all 
necessary supplies and equipment (drugs and nursing visits coded separately), per diem. 
 
We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status code 
of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code 
for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for 
coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy services provided from December 23, 2019 to March 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair for the enrollee. 
 
You asked the Plan to pre-approve the wheelchair. You say that this will enable the enrollee to be able to get to 
his mailbox. The Plan denied your request. The Plan says there was no assessment provided showing that the 
enrollee's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of 
this vehicle. 
 
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.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the 
documentation does not consistently reveal that the enrollee's personal mobility deficit impairs participation in 
MRADLs in the home and is needed for MRADLs in the home. The enrollee's deficit is currently helped by a 
walker. The medical progress report documentation reveals the patient has 5/5 strength in the right arm, 5/5 in 
both legs and 4/5 in the left arm. The seating and mobility evaluation notes the BUE strength is 5/5 and normal 
tone. Range of motion is normal. These findings are inconsistent with the medical progress report stating that 
he cannot perform ADLs due to poor upper body strength. Furthermore, the mobility evaluation indicates this 
wheelchair is primarily for out of the apartment not for MRADLs. Per the records, a prior DME consulting 
report indicated he had no falls in the home and is a household ambulator and has caregiver assist out of the 
home and a transport chair was more appropriate. The recent medical progress reports do not indicate any 
evidence of falls in the home. Given the multiple inconsistencies in the documentation it is not clear that the 
enrollee requires a power mobility device to perform MRADLS in the home. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair for the enrollee.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on April 18, 
2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that you should owe an urgent care 
visit. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
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 a $90 
copayment for emergency care.  
 
The medical records show that you received emergency care provided on April 18, 2020. Therefore, you are 
responsible to pay the $90 copayment.  
 
You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 
care 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 copayment for emergency care provided on 
April 18, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for PT provided from October 1, 2019 to 
November 19, 2019. 
 
You asked the Plan to waive the copayments for PT. You say that you disagree with the charges because you 
are being charged twice. The Plan denied your request. The Plan says the claims were processed correctly and 
you are being charged the correct amount. 
 
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 a $30 
copayment for outpatient rehabilitation services.  
 
The record shows that you received PT from October 1, 2019 to November 19, 2019 for a total of 8 visits. 
Therefore, you are responsible to pay a $30 copayment per each visit. The total amount you owe is: $30 
(copayment) x 8 (PT visits) = $240. 
 
You have been asked to pay the total copayment amount of $240 for PT. PT falls within the outpatient 
rehabilitation services 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 copayments for PT 
provided from October 1, 2019 to November 19, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0427) provided 
on March 26, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you did not ask for the 
ambulance services. The Plan denied your request. The Plan says you were charged this cost sharing 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 a $250 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $250 for these 
services. 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 copayment for the ambulance services (A0427) provided on 
March 26, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve insertion of a leadless pacemaker for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the information provided does not show participation in a Medicare-approved 
clinical study. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 procedure. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has a history of tachy-brady syndrome and symptomatic sinus pauses of up to 8 seconds. She 
is off beta blockers and therefore meets CMS medical necessity criteria for pacemaker implantation. The 
Medtronic Micra leadless pacemaker is approved by CMS for the reimbursement of this device as part of an 
ongoing evidence development post-market approval study for completion in 2024 with retrospective data 
collection. This specific device implantation therefore meets the CMS criteria for implantation as part of an 
ongoing FDA approved evidence development study. 
 
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 procedure have been met. Therefore, we decided that the Plan has to pre-
approve insertion of a leadless pacemaker for the enrollee.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging (SPECT) for the enrollee. 
 
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is an approval code for a same or similar study that is still in effect. 
 
The Plan must follow Medicare rules. Medicare rules say that SPECT 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 imaging. Our reviewer says that the 
requested imaging is not medically reasonable or necessary. Our physician reviewer found there is no recent 
medical history, discussion of symptoms, exam findings, or assessment and plans in the limited medical notes 
provided. In the absence of a clinical explanation of medical necessity, there is no information provided here 
which meets the CMS criteria for the study. Per the health plan, there is a prior approval code for a similar or 
same study still in effect. 
 
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 imaging have not been met. Therefore, we decided that the Plan does not 
have to pre-approve myocardial perfusion imaging (SPECT) for the enrollee.