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

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC). 
 
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. Medicare rules say that a PWC is covered when specific criteria are 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 these services. Our reviewer says that 
the enrollee does not meet the criteria for coverage. Our physician reviewer found the submitted records do not 
reveal that the enrollee has a personal mobility deficit that impairs participation in mobility-related activities of 
daily living (MRADLs) in the home. Her mobility deficit can be helped by a walker. She does not meet the 
criteria for coverage of the Group 2 PWC and the services are 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 a Group 2 power wheelchair (PWC).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cancer panel provided on February 3, 2020. 
 
You asked the Plan to pay for the testing services. You say that the enrollee was mailed a test kit, and then 
mailed it back to the lab. The Plan denied your request. The Plan says the claim must reflect the location where 
the specimen was obtained. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The records provided do not indicate the enrollee's specimen was obtained 
at an independent laboratory. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for the hereditary cancer panel provided on 
February 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from July 2, 
2020, through July 9, 2020. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you started experiencing pain 
and difficulty walking so you canceled future appointments. You say that you shouldn't have to pay the 
copayments. The Plan denied your request. The Plan says the copayments applied 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 $40 
copayment per therapy type, per in-network provider, per day for physical and speech services. 
 
You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is 
$120 ($40/visit x 3 visits -= $120). Physical therapy 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 copayment for physical therapy provided from July 2, 2020, 
through July 9, 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 the services are 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. 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 
services are necessary. Our physician reviewer found the complexity of your nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for 
physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy 
program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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. 
 
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
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 you required maximum assistance to walk a few steps and with transfers. The 
documentation does not support that you require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The documentation doe snot support that you require  the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility. You care needs can be met at a 
lower level of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit (99349) provided by an out 
of network (OON) provider. 
 
You asked the Plan to pay for home visit. You say that you requested prior authorization. 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 home visit (99349) provided by an out of 
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electrical continence aid. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says there is 
no valid scientific documentation of the effectiveness and safety. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve an electrical 
continence aid.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on January 24, 2020. 
 
You asked the Plan to pay for genetic tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because the documentation 
submitted does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing 
was taken in a home setting, therefore the Place of Service (POS) code 81 ? indicating an independent 
laboratory setting ? is not appropriate for this claim. Based on this information, we decided that Medicare rules 
for coverage of genetic tests have not been met. Therefore, we decided that the Plan does not have to pay for 
genetic testing provided on January 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral appliance (E0486). 
 
You asked the Plan to pre-approve the appliance. You say that the appliance is medically necessary. The Plan 
denied your request. The Plan says rules for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that oral appliances are covered when medically 
necessary and 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 the appliance. Our reviewer says that 
the documentation does not support the need for a new appliance.  
 
 
 
 
 
Our physician reviewer found the request for a new appliance has not been accompanied by a reason why the 
current appliance is no longer functional or otherwise requires replacement. Medicare requires an explanation 
to the effect that the appliance is no longer functional and has reached the end of its useful lifespan before 
considering such a request. Documentation of the initial physician visit which initiated the sleep study must 
also be provided to satisfy the requirements 
 
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 appliance have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an oral appliance (E0486).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941), the office 
visit (99202), and the x-ray exam of the lumbar spine (72100) provided from June 1, 2020, through August 5, 
2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for the chiropractic manipulative treatment (98941), the office visit (99202), and the x-ray exam of 
the lumbar spine (72100) provided from June 1, 2020, through August 5, 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 cannot go home because your keep hurting 
yourself. The Plan denied your request. The Plan says that you can safely receive the services you need 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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for an exacerbation of multiple 
sclerosis. Your medical problems are stable. There are no identified problems that need inpatient medical 
management. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. The medical record supports a need for physical and occupational therapy but it does not support a 
need for an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our 
physician reviewer found that your 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.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services (G0493). 
 
You asked the Plan to pre-approve home health services. You say that the home health services are medically 
necessary. The Plan denied your request. The Plan says insufficient documentation has been submitted to 
support the need for home health services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
 
We looked at the file and Medicare rules. The plan made multiple requests for medical records. No medical 
records or physician order for these services were provided. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services (G0493).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Electric hand, switch or myoelectric controlled, 
independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s) 
(L6880). 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that there are no notes showing why this is 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 requested items/services are not considered medically reasonable and necessary in this case. The 
documentation does not reveal physician medical progress reports indicating why this particular hand is 
medically necessary over an alternative terminal device. The requested item appears to exceed your medical 
need. Our physician reviewer found that your condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Electric hand, switch or myoelectric controlled, independently articulating digits, any 
grasp pattern or combination of grasp patterns, includes motor(s) (L6880).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe laboratory services (86003, 82785, 36415) provided on June 10, 2020.You asked the Plan to waive the copayment forthe laboratory services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says the copayment applied correctly in this case.The rules say a plan must disclose to its enrollees inclear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $20 copayment for outpatient diagnostic tests. The enrollee has been askedto pay a $20 copayment for the laboratory services. The services provided fall within the outpatient diagnostic tests benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe laboratory services (86003, 82785, 36415) provided on June 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zolpidem tartrate for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Zolpidem tartrate for the 
enrollee.  
 
Benefits for this drug 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the abdomen (74160). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan 
denied your request. The Plan says rules 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 
CT scan is not medically necessary. Our physician reviewer found without abdominal symptoms or signs and 
no indications of a red flag diagnosis, CT abdomen is not warranted. Borderline leukocytosis alone is not 
sufficient to support this request. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve Computed Tomography (CT) of the abdomen (74160).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a cytopathology procedure (88175) 
performed on July 15, 2020. 
 
You asked the Plan to waive the deductible for a cytopathology procedure. You say that this claim should have 
processed as in-network because you went to your annual gynecological appointment. The Plan denied your 
request. The Plan says the correct cost-sharing was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $250 deductible for Medicare-covered lab tests when performed by an 
out-of-network provider.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible for 
Medicare-covered lab tests when performed by an out-of-network provider. This cost sharing is a contractual 
obligation that had not been met at the time a cytopathology procedure was received on July 15, 2020. 
Therefore, we decided that the Plan does not have to waive the deductible for a cytopathology procedure 
(88175) performed on July 15, 2020.  
 
Your complaint about your gynecologist sending your sample to an out-of-network laboratory is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthosis (L0650) provided April 8, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the item was medically necessary. The Plan denied 
your request. The Plan says the documentation does not support services billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The invoice provided shows delivery on March 9, 2020. 
April 8, 2020 was the date of service on the claim form. The record shows that the Plan made several attempts 
to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to 
pay for an orthosis (L0650) provided April 8, 2020.