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

We decided that the Plan does not have to pre-approve the power wheelchair. 
 
You asked the Plan to pre-approve the power mobility device. You say that the enrollee requires a power 
wheelchair because he has difficulty with manual. The Plan denied your request. The Plan says the enrollee can 
participate in MRADLs so he does not meet Medicare criteria for coverage. 
 
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 power mobility device. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found Medicare allows for a 
power-wheelchair when the Member cannot perform activities of daily living with the assistance of an 
appropriate manual wheelchair. The medical notes provided support the Member should be able use an 
appropriate manual chair to complete basic activities of daily living. The review has determined that this 
enrollee does not have a personal mobility deficit that impairs participation in MRADLs. The enrollee mobility 
deficit be helped by the use of a walker, cane or manual wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the power mobility device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the power wheelchair.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on April 25, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 25, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on April 
25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. You say that the authorization for inpatient 
treatment should be approved. The Plan denied your request. The Plan says they will partially overturn the 
initial determination, but not the continued dates from January 6, 2021 onward. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric treatment. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the health plan?s denial 
of continued inpatient psychiatric services is appropriate. This enrollee did not appear to require inpatient 
mental health treatment beyond the date in question as she was not a danger to herself or others, no auditory 
hallucinations or visual hallucinations while being cooperative with treatment. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services were reasonably 
expected to improve the patient?s condition or for the purpose of diagnosis beyond the date in question. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies including wipes (A4335), Liners 
(A4520), and disposable under pads (A4554). 
 
You asked the Plan to pre-approve incontinence supplies. You say that you would like these supplies to be 
covered. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that other supplies used in the management of incontinence involving but not limited to ( 
A6250) creams, salves, lotions, wipes; (A4554) disposable under pads and (A4520) diapers or incontinence 
garments, will be deemed as noncovered because they are not prosthetic devices nor are they required for the 
effective use of a prosthetic device. Therefore, based upon this criteria, the requested incontinence supplies are 
non-covered. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies including 
wipes (A4335), Liners (A4520), and disposable under pads (A4554).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abdominal panniculectomy (15830). 
 
You asked the Plan to pre-approve an abdominal panniculectomy. 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 follows Medicare rules. Medicare rules say that panniculectomy will be considered medically 
necessary when the pannus or panniculus hangs below the level of the pubis, and the medical records document 
that the panniculus causes chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin 
irritation, infection or chafing) that consistently recurs over three months while receiving appropriate medical 
therapy, or remains refractory to appropriate medical therapy over a period of three months. 
 
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 an abdominal panniculectomy. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the degree of 
severity of pannus overhang has not been defined (photographs were not provided as well) and conservative 
management/medical therapy was not documented. 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an abdominal panniculectomy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an abdominal panniculectomy (15830).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the enrollee requires the device. The Plan 
denied your request. The Plan says you do not meet Local Coverage Determination guidelines for coverage. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer says 
that the service is not necessary. Our reviewer found the member does not have qualifying hypercapnia. Pulse 
oximetry showing nocturnal desaturation has not been documented. There is no evidence of consideration or 
exclusion of obstructive sleep apneaThe member does not have life-threatening conditions where interruption 
of respiratory support would quickly lead to serious harm or death.  Thus, the denial for an E0466 Home 
ventilator, any type, used with noninvasive interface, (e.g., mask), which is a mechanical ventilator with 
functionality that exceeds that of an E0470 or E0471 device, is consistent with Medicare regulations. 
 
 
 
 
 
 
We looked at this review, the file, and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a portable ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the maxillary partial denture. The Plan denied your request. The Plan says 
this service is 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 
maxillary partial denture (D5213).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the maxillofacial 
area (70486). 
 
You asked the Plan to pre-approve a CT scan of the maxillofacial area. 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. 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 a CT scan of the maxillofacial area. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon the 
records submitted, the medical necessity of a CT of the sinuses has not been established. 
 
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 CT scan of the maxillofacial area have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a computed tomography (CT) scan of the maxillofacial area (70486).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove wheelchair components defined by codes E2300, E2377, 
E2313, E2311. 
 
You asked the Plan to preapprove the wheelchair components.. You say that the power mobility device and all 
the components are necessary. The Plan denied your request. The Plan says the power wheelchair is covered, 
but the specified options and accessories are not. 
 
The Plan follows Medicare rules. Medicare rules say requested the additional components are to control power 
tilt, recline and power elevating leg rests through the joystick. The notes state that these are needed when 3 or 
more actuators are being used. The electrical connection between the wheelchair controller and two or more 
motors (E2311), expandable controller (E2377) and harness (E2313) cannot be covered.  
 
The file shows that there is not a medical need to control these power options through the joystick. 
Documentation shows that the member has 4/5 wrist and 3+/5 finger strength and can feed himself 
independently. Member's upper limb strength and function are adequate for the member to be able to control 
the power options using their own switches which are included in the allowance of these power options.  This 
means that Medicare rules for coverage of the additional components have not been met. Therefore, we decided 
that the Plan does not have to preapprove wheelchair components defined by codes E2300, E2377, E2313, 
E2311.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on June 21, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 21, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on June 
21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a spinal canal injection provided on 
September 17, 2020. 
 
You asked the Plan to waive the copayment for a spinal canal injection. You say that you were told that the 
procedure would be covered in full. 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 $500 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay a $500 copayment for a spinal canal injection. A spinal canal injection falls within 
the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers 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 a spinal canal injection provided 
on September 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal electrical osteogenesis stimulator (E0748). 
 
You asked the Plan to pre-approve a spinal electrical osteogenesis stimulator. 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 follows Medicare rules. Medicare rules say that a spinal electrical osteogenesis stimulator is covered 
when specific criteria is met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a spinal electrical osteogenesis 
stimulator. Our reviewer says that the item is not medically necessary. Our physician reviewer found criteria 
for a stimulator is not met. There is no multilevel spine fusion. There is not greater than 9 months since 
surgery. A stimulator is not needed. 
 
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 spinal electrical osteogenesis stimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a spinal electrical osteogenesis stimulator (E0748).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epclusa tablets. 
 
You asked the Plan to pre-approve the Epclusa tablets. The Plan denied your request. The Plan says this drug is 
not covered for your condition by Medicare 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 Epclusa tablets.  
 
Benefits for Epclusa tablets 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nurtec Tablets. 
 
You asked the Plan to pre-approve the Nurtec Tablets. You say that the enrollee has been taking Maxalt, but 
continues to have severe headaches. You also say that the enrollee needs to take Nurtec due to their severe 
headaches. The Plan denied your request. The Plan says this medication does not fall 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 Nurtec Tablets.  
 
Benefits for the Nurtec Tablets 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a wheelchair provided on September 8, 
2020. 
 
You asked the Plan to waive the coinsurance for wheelchair. You say that you were under the impression that 
this wheelchair had been purchased and were not expecting to pay for rent. The Plan denied your request. The 
Plan says the coinsurance amount you are being charged is correct. 
 
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 20% 
coinsurance for in-network wheelchair. The allowed amount of this claim is $148.28, resulting in a coinsurance 
obligation of $29.66. 
 
You have been asked to pay 20% coinsurance for wheelchair. Wheelchair falls within the Durable Medical 
Equipment (DME) and Related Supplies 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 coinsurance 
for a wheelchair provided on September 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy (S9328) provided July 9, 2020, to 
August 13, 2020. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the services as billed are not eligible 
for coverage. 
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home infusion therapy services have not been met. Specifically, the code billed (S9328) is not 
covered by Medicare or the Plan. Medicare uses another code for reporting of, and payment for, these services. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (S9328) 
provided July 9, 2020, to August 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a heavy-duty wheelchair with tilt and recline. 
 
You asked the Plan to preapprove a heavy duty wheelchair. You say that you require a heavy-duty wheelchair 
with tilt and recline because you've had falls and the current wheelchair you have isn't right. The Plan denied 
your request. The Plan says you were accessed to need a Group 2 power wheelchair, and you have that 
wheelchair.  
 
The Plan must follow Medicare rules. Our records show the enrollee was evaluated by Maxim Healthcare.  
Based on the report the most appropriate item at that time was a group 2 powered wheelchair. The records also 
show you were recently evaluated by DME Consulting Group and that report states your current group 2 
powered wheelchair is in good condition, fits you properly and meets all your needs so the request for the 
heavy duty powered wheelchair with tilt and recline has been denied. Therefore, we decided that the Plan does 
not have to preapprove a heavy-duty wheelchair with tilt and recline.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services provided on June 30, 
2020. 
 
You asked the Plan to pay for the subsequent hospital care 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 99232 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We find that CPT code 99232 is not supported in the medical record. Specifically, this service was provided 
within the global period of a procedure. This code was billed with an inappropriate modifier. An appropriate 
modifier is required for payment. Based on this information, we decided that Medicare rules for coverage of the 
subsequent hospital care services have not been met. Therefore, we decided that the Plan does not have to pay 
for the subsequent hospital care services provided on June 30, 2020.