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

 
We decided that the Plan does not have to pre-approve a multi-purpose sharps container. 
 
You asked the Plan to pre-approve the container. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a multi-purpose sharps container.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for inpatient total right ankle 
arthroplasty. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are three participating providers available in the network who can provide the 
service. 
 
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 
an out-of-network referral for inpatient total right ankle arthroplasty.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Liquid Liquid CDx panel provided on 
March 17, 2021. 
 
You asked the Plan to pay for the FoundationOne Liquid CDx panel. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says this testing is 
considered experimental and the enrollee does not have out-of-network benefits. 
 
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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the FoundationOne Liquid Liquid CDx 
panel provided on March 17, 2021. have been met. Specifically, the documentation submitted does not include 
any clinical records to determine why this testing was ordered, if it was medically necessary and how the 
results will affect the enrollee's treatment.. Therefore, we decided that the Plan does not have to pay for the 
FoundationOne Liquid Liquid CDx panel provided on March 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON diabetic shoes. You say that the Plan no longer uses Hanger for 
diabetic shoes. It is stated that the requested provider is the only one able to provide custom diabetic shoes with 
a orthotist on site. The Plan denied your request. The Plan says there is a network supplier that can provide the 
services being requested. 
 
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 
diabetic shoes to be 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 a group 3 power wheelchair and multiple accessories. 
 
You asked the Plan to pre-approve the services. You say that the current chair is inoperable beyond repair. The 
Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients 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 services. Our reviewer says that the 
requested wheelchair is not medically reasonable or necessary. Our physician reviewer found you do not meet Medicare criteria for the requested group 3 power wheelchair and multiple accessories including power 
tilt/recline. The provided records do not document you are at high risk for developing pressure ulcers and are 
unable to perform pressure relief or that she utilizes bladder self-catheterization or has increased muscle tone or 
spasticity.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair and multiple accessories.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services performed by a qualified physical therapist 
(G0151), services performed by a qualified speech-language pathologist (G0153), home health aide (HHA) 
services (G0156), and direct skilled nursing services of a registered nurse (RN) (G0299). 
 
You asked the Plan to pre-approve services performed by a qualified physical therapist and speech-language 
pathologist, HHA services, and direct skilled nursing services of a RN. The Plan denied your request. The Plan 
says the documentation submitted indicates the request is custodial in nature and does not support medical 
necessity. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services performed by a qualified 
physical therapist and speech-language pathologist, HHA services, and direct skilled nursing services of a RN. 
Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer 
found the documentation does not support that the enrollee requires skilled nursing services to provide 
treatment that is medically necessary. The enrollee does not require skilled nursing services to effectively 
provide treatment, care, and/or services in order to improve the enrollees condition, perform a maintenance 
program to maintain the enrollees condition and/or prevent deterioration. Our reviewer found that the enrollee 
has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 
There is no indication for skilled nursing or home health aide services. The enrollee requires custodial care. 
Our physician reviewer also found that although the enrollee has had a decline in strength resulting in more 
difficulty with transfers, there is no documented signed physician order for skilled rehabilitation from January 
15, 2022, to March 15, 2022. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of services performed by a qualified physical therapist and speech-language 
pathologist, HHA services, and direct skilled nursing services of a RN have not been met. Therefore, we 
decided that the Plan does not have to pre-approve services performed by a qualified physical therapist 
(G0151), services performed by a qualified speech-language pathologist (G0153), home health aide (HHA) 
services (G0156), and direct skilled nursing services of a registered nurse (RN) (G0299).
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. The Plan denied your request. The Plan says the services are 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 in the Medicare rules section. 
 
 
  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 the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Our 
physician reviewer also found that there is not a reasonable expectation that this patient 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bilateral knee braces with suspension sleeves provided on 
November 19, 2021. 
 
You asked the Plan to pay for the knee braces with sleeves. You say that this was ordered by the treating 
physician after a face-to-face examination. They are medically necessary for the enrollee's condition. The Plan 
denied your request. The Plan says though these were ordered by the provider, the enrollee has indicated she 
did not need them and was not seen to have them ordered. 
 
The Plan must follow Medicare rules. Medicare rules say that knee braces may be covered for enrollees with a 
recent injury or surgical procedure of the knee, or for an ambulatory enrollee with knee instability. 
 
The only note provided by the ordering provider shows that no physical examination of the knee was 
performed. There is no evidence of any complaint of knee injury or pain, and no evidence that the enrollee 
reported or was found to have instability. Without any evidence of a need or intent to provide knee braces in the record provided, we find that the criteria for coverage are not met. Therefore, we decided that the Plan does 
not have to pay for the bilateral knee braces with suspension sleeves provided on November 19, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (81404 and 81479) provided on September 13, 
2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that this service was not ordered by the 
enrollee's treating physician. 
 
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. Specifically, the documentation submitted does not include the appeal or lab 
report which were used to support the Plan's denial. It is the burden of the Health Plan to substantiate their 
denial with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. 
Therefore, we decided that the Plan has to pay for the laboratory services (81404 and 81479) provided on 
September 13, 2021.  
 
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: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the anesthesia services coded as 00811. We decided that the Plan does 
not have to pay for the special anesthesia services coded as 99100.  
 
You asked the Plan to pay for the anesthesia services coded as 00811. You say that the records support that the 
claim should be paid. The Plan says that the code 00811 is not appealable. Code 99100 is not payable since it is 
bundled in payment for the primary code. 
 
We decided that the Plan has to pay for the anesthesia services coded as 00811.  
 
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 code 00811 was denied on February 4, 2022, for requested information not being received. That such 
information was received as an appeal request would not exempt the code from an appeal determination. Since 
the Plan forfeited the opportunity to provide a valid denial rationale, we find that the denial is not substantiated. 
Therefore, we decided that the Plan has to pay for the anesthesia services coded as 00811.  
 
We also decided that the Plan does not have to pay for the special anesthesia services coded as 99100. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code 99100 has a status indicator of B in the Medicare Physician Fee Schedule. This means that payment for 
the service is bundled into payment for other services. Therefore, we decided that the Plan does not have to pay 
for the special anesthesia services coded as 99100. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diabetic shoe for a density insert (A5500) and a 
multiple density insert custom mold (A5513) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve foot orthotics. You say that the provider is close to your home. The Plan 
denied your request. The Plan says the requested service is available in-network. 
 
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 
a diabetic shoe for a density insert (A5500) and a multiple density insert custom mold (A5513) to be provided 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services and special staining provided 
on October 7, 2021. 
 
You asked the Plan to pay for the pathology and testing services. You say that the services rendered were 
medically necessary and should be paid. The Plan denied your request. The Plan says the POS code reported on 
the claim is not matching the location in which the sample for testing was collected. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the pathology and testing services have not been met. Specifically, this claim was billed with the 
laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, 
we decided that the Plan does not have to pay for the surgical pathology services and special staining provided 
on October 7, 2021.
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 reconsideration because the 
requested IRF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet Medicare criteria for coverage of IRF care. 
 
`The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for lumbar spine surgery. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that this enrollee 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 believe that you need intensive rehabilitation 
services. The Plan denied your request. The Plan says this level of care 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 in the Medicare rules section. 
 
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 the complexity of the members nursing, medical and rehabilitation needs do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this 
individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. 
 
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 moderate sedation services provided on June 27, 2021, 
billed with code 99153. 
 
You asked the Plan to pay for the sedation services as billed. You say that payment should be made for these 
services. The Plan denied your request. The Plan says 99153 cannot be paid in the place of service. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and is 
not paid in the facility setting.  
 
We looked at the file and Medicare rules. The services described by 99153 are not payable to a physician when 
done in the facility setting.  
 Based on this information, we decided that Medicare rules for coverage of the sedation services as billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services 
provided on June 27, 2021, billed with code 99153.