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

We decided that the Plan does not have to pre-approve a chair with a seat lift mechanism. 
 
You asked the Plan to pre-approve the seat lift mechanism. You say that the enrollee has had multiple falls and 
it is felt that having this lift chair will help his spouse to be able to get him around the house safely. The Plan 
denied your request. The Plan says there is no documentation that the criteria are met. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed above are met. 
 
In this case, the records provided show a diagnosis of osteoarthritis, but they do not indicate whether this is 
severe and if it is in the hip or knee and no documentation is given of severe neuromuscular disease. There is 
also no documentation that the enrollee is completely unable to get up from a regular arm chair. Therefore, we 
decided that the Plan does not have to pre-approve a chair with a seat lift mechanism.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prosthesis services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the prosthesis services. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent 
to seek out-of-network care. The Plan says there are equally qualified in-network providers available that can 
provide the prosthesis you are requesting. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the prosthesis services to be provided by an out of network (OON) provider.
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 stay is 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 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 patient appears to not be stable, with percutaneous endoscopic gastrostomy (PEG) 
feeding not functioning at the time, requiring additional short term acute care services at this time which can be 
completed in the current setting. The patient does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that the patient requires that are not 
already available and covered at the current setting. Therefore, this request for LTACH services will be 
considered not medically necessary at this time. Transfer may be considered when more stable. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you require multiple medical appointments 
and have no access to transportation due to your limited income. You feel that more trips should be allowed for 
you. The Plan denied your request. The Plan says your plan only covers 24 one-way trips. No trips beyond this 
limit are covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for influenza diagnostic testing (87633) provided to the enrollee 
on April 14, 2020. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says based on the medical records provided, this code was not billing appropriately. 
 
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 records provided do not show 
this testing was billed or used appropriately. Medicare rules for coverage of this testing have not been met. 
Therefore, we decided that the Plan does not have to pay for influenza diagnostic testing (87633) provided to 
the enrollee on April 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve a complete upper denture and complete lower denture. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
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. The Plan covers complete 
dentures once every 5 years. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a complete upper denture and complete lower denture have not been met. The plan covers 
complete dentures once every five years. The record shows that you received complete dentures on June 6, 
2019. This means that you are not eligible for health plan coverage of complete dentures at this time. 
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and 
complete lower denture (D5120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 2, 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 March 2, 2020 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a post/core for use with a crown (D2954) for tooth #10. 
 
You asked the Plan to pre-approve the post/core. You say that you feel that this should be covered. The Plan 
denied your request. The Plan says the crowns have been approved, but post/cores for crowns 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
post/core for use with a crown (D2954) for tooth #10.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
March 19, 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 enrollee has previously received the same supplies within the 5-year RUL. 
 
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical 
equipment is no less than five years. Replacement equipment may be granted when irreparable wear or 
irreparable damage is demonstrated or there has been a change in the enrollee's medical condition.  
We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the 
enrollee has received the same durable medical equipment on February 16, 2018. This orthosis is still within 
the 5-year RUL and the documentation submitted does not show that the orthosis is irreparably worn, 
irreparably damaged, or that the enrollee had a change in medical condition to warrant the orthosis at issue.  
Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. 
Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the 
enrollee on March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injection services to be provided by an 
out of network (OON) provider. 
 
You asked the Plan to pre-approve the facet joint injection services. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent 
nor urgent to seek out-of-network care. The Plan says there are equally qualified in-network providers available 
to you that can provide the care you are requesting. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the facet joint injection services to be provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy evaluation services coded 97163 
provided on July 22, 2019. 
 
You asked the Plan to pay for the physical therapy evaluation services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not 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 97163 is physical therapy evaluation: high complexity, 
requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities 
that impact the plan of care; An examination of body systems using standardized tests and measures addressing 
a total of 4 or more elements from any of the following: body structures and functions, activity limitations, 
and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and 
Clinical decision making of high complexity using standardized patient assessment instrument and/or 
measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient 
and/or family. 
 
We find that CPT code 97163 is not supported in the medical record. Specifically, this service should be billed 
when services are provided by a licensed physical therapist. Review of the file shows that the services were 
provided by a physical therapist assistant and not provided by a licensed physical therapist. Based on this 
information, we decided that Medicare rules for coverage of the physical therapy evaluation services have not 
been met. Therefore, we decided that the Plan does not have to pay for the physical therapy evaluation services 
coded 97163 provided on July 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that LTACH Admission is medically necessary.The Plan denied your request. The Plan says the enrollee can receive same services at the current level of care.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rulesto 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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, thatare not available at the current health care setting being offered by the health plan.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-approvelong-term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve factor V testing for the enrollee. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show venous thromboembolism. 
 
The Plan must follow Medicare rules. Medicare rules say that factor V testing can be covered for individuals 
with factor V testing.  
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the review has determined that the enrollee does not have evidence of venous thromboembolism to 
indicate the requested testing. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve factor V testing for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an external transmitter for use with a continuous 
glucose monitoring (CGM) system (A9277). 
 
You asked the Plan to pre-approve an external transmitter for a CGM. You say that the item is necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that code A9277 is not a covered item. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an external transmitter for a CGM have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an external transmitter for use with a continuous glucose monitoring (CGM) system 
(A9277).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on October 24, 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 procedure code 15004 is not supported. 
 
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 15004 is surgical preparation or creation of recipient site 
by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar 
contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 
sq cm or 1% of body area of infants and children. 
 
The definition of code 15002 is surgical preparation or creation of recipient site by excision of open wounds, 
burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; 
first 100 sq cm or 1% of body area of infants and children. 
 
The definition of code 15003 is surgical preparation or creation of recipient site by excision of open wounds, 
burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; 
each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List 
separately in addition to code for primary procedure). 
 
We find that CPT codes 15002, 15003, and 15004 is not supported in the medical record. Specifically, the 
operative report did not include documentation of surgical preparation or creation of a recipient site by excision 
of open sounds, burn eschar, or scar for the first 100 sq cm to support codes 15002 and 15004. The operative 
report does not include documentation of surgical preparation or creation of a recipient site by excision of open 
wounds for each additional 100 cm sq to support code 15003. Code 15005 is an add-on code and is not 
supported given that the primary procedure code is not supported. 
 
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 surgical services rendered on October 24, 
2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (81292, 81295, 81298, 81317, 81321, 
81401, 81403, 81404, 81405, 81406, 81407, 81408, 88237, 81201, 81162, 81163, 81164) provided on February 
11, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that the services rendered were medically necessary. 
The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network provider. 
 
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 genetic testing (81292, 81295, 81298, 81317, 
81321, 81401, 81403, 81404, 81405, 81406, 81407, 81408, 88237, 81201, 81162, 81163, 81164) provided on 
February 11, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a percutaneous left atrial appendage 
closure (LAAC) (Watchman implant). 
 
You asked the Plan to pre-approve Watchman implant. You say that the enrollee cannot take anticoagulation 
medication due to her religious beliefs. The Plan denied your request. The Plan says the denial of authorization 
for this service is correct, because there is no documentation that the enrollee had a formal shared decision-
making interaction with an independent non-interventional physician using evidence-based decision tools on 
oral anticoagulation, and the record shows the enrollee is currently on Eliquis. 
 
The Plan follows Medicare rules. Medicare rules say that a percutaneous LAAC may be covered through 
Coverage with Evidence Development (CED) if certain clinical criteria have been 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 Watchman implant. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested percutaneous LAAC. Our physician 
 
 
reviewer found the enrollee has atrial fibrillation and increased thromboembolic risk but taking, and tolerating, 
Eliquis without bleeding complications. In this circumstance of compliance and tolerance with Eliquis, 
coverage criteria for placement of a Watchman device is not met. The documentation does not support that the 
enrollee is unable to continue cautious use of Eliquis in this setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Watchman implant have not been met. Therefore, we decided that the Plan does 
not have to pre-approve placement of a percutaneous left atrial appendage closure (LAAC) (Watchman 
implant).