Persius/hicric huggingface dataset:
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 is medically necessary. The Plan denied 
your request. The Plan says the requested power wheelchair and its components cannot be considered 
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 wheelchair. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation is not clear on what MRADLs in the home are affected. There is no detailed 
medical progress notes with a neurological, musculoskeletal exam, or gait evaluation by a physician or 
qualified medical provider. There is no indication of clear and objective reasons why the mobility deficit 
cannot be helped by the use of a walker, cane, or manual wheelchair, or if the enrollee can safely operate a 
PMD. The enrollee does not have a neurological condition, myopathy, or a congenital skeletal deformity that 
would indicate a group 3 chair or evidence that the enrollee uses a ventilator. There is no objective medical 
progress report from a physician or qualified medical provider that indicates a need for tilt and recline. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve portable oxygen. 
 
You asked the Plan to pre-approve portable oxygen. You say that portable oxygen is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of portable 
oxygen. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 portable oxygen. Our reviewer says that 
portable oxygen is not medically necessary at this time. Our physician reviewer found it is not documented that 
the enrollee's oxygen saturation was at or below 88% at rest, or that the qualifying blood gas study was 
obtained closest to, but no earlier than 2 days prior to, the hospital discharge date. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of portable oxygen have not been met. Therefore, we decided that the Plan does 
not have to pre-approve portable oxygen.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultra-lightweight manual wheelchair (K0005) with 
accessories. 
 
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 is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the wheelchair. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you were unable to be fitted and adjusted for a K0001 through K0004. The documentation 
indicates on a 6/5/20 DME consultation that a lightweight, hemi-height manual wheelchair with removable 
armrests (K0003) would be the most appropriate wheelchair for you. 
 
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 an ultra-lightweight manual wheelchair (K0005) with accessories.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for orthopedic shoes (L3216) received on March 26, 2020. 
 
You asked the Plan to pay for orthopedic shoes. You say that the orthopedic shoes are attached to full-length 
leg braces. The Plan denied your request. The Plan says that rules for payment for orthopedic shoes have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Medicare rules state that supportive devices for the feet (such as orthotics) are 
only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these 
same rules. In this case, you have stated that the orthopedic shoes are part of a leg brace. The Plan has not 
provided medical records to support its assertion that you do not wear a leg brace and that you do not have 
diabetes. Therefore, we decided that the Plan has to pay for orthopedic shoes (L3216) received on March 26, 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 6, 
2020 to February 7, 2020. 
 
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says the 
enrollee's care could have been provided at a lower level. 
 
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 the 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 that the record did not show that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier 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 the 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 6, 2020 to February 
7, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve One Touch Ultra Blue test strips (A4253). 
 
You asked the Plan to pre-approve One Touch Ultra Blue test strips. You say that the enrollee needs test strips 
to check his glucose level. The Plan denied your request. The Plan says the enrollee must use a preferred brand 
of test strips. 
 
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those 
preferred brands and manufacturers, as long as the above conditions are met. The Plan's preferred brands for 
diabetic supplies are CCU-CHEK manufactured by Roche, or Trividia products. 
 
We looked at the file and Medicare rules. No medical records or other documentation demonstrating why it is 
medically necessary for the enrollee to use a non-preferred product have been submitted. Based on this 
information, we decided that Medicare rules for coverage of One Touch Ultra Blue test strips have not been 
met. Therefore, we decided that the Plan does not have to pre-approve One Touch Ultra Blue test strips 
(A4253).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-covered chiropractic services (97032, 97810, and 
97811) provided from January 3, 2020 to April 2, 2020. 
 
You asked the Plan to pay for the non-covered chiropractic services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the non-covered chiropractic services (97032, 97810, and 97811) 
provided from January 3, 2020 to April 2, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study. 
 
You asked the Plan to pre-approve a sleep study. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that sleep studies are covered for the above indications. 
 
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 sleep study. Our reviewer says that 
the requested sleep study is not medically reasonable and necessary. Our physician reviewer found that the 
enrollee has a history of obstructive sleep apnea. He uses CPAP nightly for 6 hours and feels well. There is no 
download information from his current CPAP machine. The enrollee in this case does not meet the NCD 
criteria for coverage of the requested sleep 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 a sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve panniculectomy to remove excess skin. 
 
You asked the Plan to pre-approve panniculectomy. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested 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 panniculectomy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have a large symptomatic abdominal pannus. Due to your current body mass index and 
history of radiation therapy, you are noted not to be a good surgical candidate for a panniculectomy. Although 
the procedure may help to resolve your functional impairment, the requested surgery is not felt to be safe for 
you. Therefore, you do not meet criteria for the requested 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 panniculectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve panniculectomy to remove excess skin.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle x-ray rendered on March 21, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 73600 is 2. You billed 3 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the ankle x-ray rendered on March 21, 2020.
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. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of authorization for IRF service is correct. 
 
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 that there is no evidence of complex medical issues that require monitoring by an 
inpatient rehabilitation physician 3 times per week or need for acute rehabilitation nursing care. While the 
enrollee may benefit from additional physical therapy and occupational therapy, at the current functional level 
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. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Farxiga. 
 
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 self-administered drugs are not covered. 
 
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 Farxiga.  
 
Benefits for these services 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on January 20, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0481 (1 Unit) remains not 
supported. 
 
The Plan must follow Medicare rules. 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 drug testing services 
provided to the enrollee on January 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on January 29, 2020.
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not support the lab services billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is requested for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services for dialysis care that you provided on 
October 31, 2019. 
 
You asked the Plan to pay for the physician's services for dialysis care. You say that the patient was in dire 
need of dialysis treatment for his condition and you could not resist treating the patient. 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 
services at issue. 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 for dialysis care that you provided on 
October 31, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0480 provided on September 4, 
2019. 
 
You asked the Plan to pay for the drug testing. 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. 
 
In this case, the CPT Code Manual definition of code G0480 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug 
class(es), including metabolite(s) if performed. 
 
We find that CPT code G0480 is not supported in the medical record. Specifically, the documentation 
submitted did not include a valid physician order/lab requisition form or medical records signed by the ordering 
physician stating exactly what tests were to be performed. Based on this information, we decided that Medicare 
rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the drug testing coded G0480 provided on September 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis, periodic oral evaluation provided on
December 19, 2019 and the crown provided February 18, 2020.
You asked the Plan to pay for the prophylaxis, periodic oral evaluation and crown. You say that the dentist was
in-network when you purchased the plan. You say that the services should be paid as in-network. The Plan
denied your request. The Plan says out-of-network dental services are not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
prophylaxis, periodic oral evaluation provided on December 19, 2019 and the crown provided February 18,
2020.