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

 
We decided that the Plan does not have to pre-approve FreeStyle Libre 2 sensors. 
 
You asked the Plan to pre-approve FreeStyle Libre 2 sensors. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says you do not meet criteria for the requested supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and related supplies are 
considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three 
daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen 
and diabetes treatment plan.  
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of FreeStyle 
Libre 2 sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve FreeStyle 
Libre 2 sensors.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with an oncologist (99214) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you have already done the CT scan and blood 
exams requested by this provider. You would like a follow up visit to go over the results. The Plan denied your 
request. The Plan says a tertiary provider is not approved when the service can be done safely within the 
contracted provider network. There are in-network providers who can provide this 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 office visit with an oncologist (99214) 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 portable walk-in whirlpool tub. 
 
You asked the Plan to pre-approve a portable walk-in whirlpool tub. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested item 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 portable walk-in whirlpool tub.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve selective catheter placement, arterial system; initial third order or 
more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family (Current 
Procedural Terminology (CPT) code 36247) and revascularization, endovascular, open or percutaneous, 
femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes 
angioplasty within the same vessel, when performed (37227). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that it is documented that the enrollee's symptoms are significantly affecting his activities of daily living. 
Guideline-directed therapy has included aggressive hypertension therapy, antiplatelet agents, diabetes 
management, and statin therapy. There has been minimal to no improvement. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or 
lower extremity artery branch, within a vascular family (Current Procedural Terminology (CPT) code 36247) 
and revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with 
transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed 
(37227).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial and are requesting 
reconsideration. The Plan denied your request. The Plan says an intensive rehabilitation program 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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not require intensive physician and nursing oversight in an IRF. While the enrollee may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that he requires this therapy on an intensive IRF level. 
 
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 pre-approve dialysis services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the dialysis services. The Plan denied your request. The Plan says the 
information received does not show evidence that transferring your hemodialysis service from one provider to 
another will affect your health status, that you need to stay with the out-of-network provider for reasons of time 
and distance that this change could worsen any mental or physical health crisis or hospitalization for that reason 
or that you have had frequent hospitalizations or deterioration in your health status. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve dialysis 
services to be provided by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 27, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair and accessories 
(K0861, E0955, E2311, E2622, E0956, E1028, E2620, E1007, E1012, E2361, E2377, K0040, E0953). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested power 
wheelchair and accessories are medically necessary for the enrollee. The Plan denied your request. The Plan 
says the enrollee does not have a medical need for multiple power options included with a group 3 power 
wheelchair. 
 
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 a power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no 
documentation that the group 3 power wheelchair with multiple power options (power tilt and power recline) at 
issue in this case meets Medicare criteria for medically reasonable and necessary. Provided records do not 
document that the enrollee is high risk for skin breakdown, has a history of pressure ulcer(s) or has had skin 
flap surgery. Records do not document the enrollee performs bladder self-catheterization or that he has 
increased muscle tone or spasticity to meet criteria for the multiple power options (power tilt and power 
recline). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 standard power wheelchair and accessories (K0861, 
E0955, E2311, E2622, E0956, E1028, E2620, E1007, E1012, E2361, E2377, K0040, E0953).
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 enrollee would benefit from IRF care. The Plan 
denied your request. The Plan says the enrollee does not meet requirements for approval 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 that on review of the available records, the enrollee with history of right hip fracture, 
treated with surgery does not meet Medicare criteria for IRF admission. No acute rehab nursing needs are identified or documented. The enrollee does not need intensive therapies consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach in an IRF. While the enrollee may 
benefit from continued physical and occupational therapy, the enrollee's rehab needs can be safely provided in 
a lower intensity and alternate 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 50 routine transportation trips and 30 
additional convenience care trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you would like additional trips approved to 
get you through the end of the year. The Plan denied your request. The Plan says as of August 24, 2022, you 
used 97 routine transportation trips, and had 3 trips remaining. The Plan also says that as of August 24, 2022, 
you used 21 Convenient Care trips, and had 3 remaining. 
 
 
 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 Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 100 one-way routine transportation trips, and up to 24 one-way 
Convenient Care transportation 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 will have, or have, exhausted the Plan maximum benefit for coverage of routine transportation and 
Convenient Care trips. Therefore, we decided that the Plan does not have to pre-approve an additional 50 
routine transportation trips and 30 additional convenience care trips.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 72128 and 72131 billed for date of service 
April 22, 2022. 
 
You asked the Plan to pay for procedure codes 72128 and 72131. You say that the enrollee had multiple exams 
on the date in question. The Plan denied your request. The Plan says payment for codes 72128 and 72131 is 
bundled into payment for codes 72129 and 72132. 
 
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, we have confirmed that code 72128 
is a column II code to column I code 72129. This claim has not been billed with an appropriate modifier to 
bypass the edit. In addition, we have confirmed that code 72131 is a column II code to column I code 72132 
with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 72128 and 72131 billed for date of service April 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says you can continue to receive services at the current hospital. 
 
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 records show that you are receiving appropriate care at the present acute care 
hospital. You do not require services at the LTACH that are not available at the acute care hospital where you 
are currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 30, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on April 5, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a specialist office visit. You say that prior authorization was obtained from the 
primary care provider (PCP) well before the services were rendered. You also say the service is medically 
necessary. The Plan denied your request. The Plan says the referring provider, the attending provider, and the 
facility are non-participating providers with the Plan. The Plan also says that they did not authorize any 
services for these providers. 
 
 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 had network providers 
available who could have provided 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 a specialist office visit provided on April 5, 2022, 
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 knee orthosis (L1851). 
 
You asked the Plan to pre-approve a knee orthosis. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says medical-necessity rules for the requested item have 
not been met. 
 
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 a knee orthosis. Our reviewer says that 
the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documentation of knee instability. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (L1851).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair with multiple power 
options. 
 
You asked the Plan to pre-approve the group 2 power wheelchair with multiple power options. You say that the 
wheelchair is medically necessary. The Plan denied your request. The Plan says the requested wheelchair 
exceeds the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that a group 2 power wheelchair is covered when 
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 group 2 power wheelchair with 
multiple power options. Our reviewer says that the requested power wheelchair and features are not medically 
necessary. Our physician reviewer found the records do not document that the enrollee is high risk for skin 
breakdown, has a history of pressure ulcer(s) or has had skin flap surgery. Records do not document the 
enrollee performs bladder self-catheterization or that she has increased muscle tone or spasticity to meet criteria 
for the power tilt and recline. Provided records do not document the enrollee has a musculoskeletal condition or 
the presence of a cast or brace which prevents 90 degree flexion at the knee; or the enrollee has significant 
edema of the lower extremities that requires an elevating leg rest. 
 
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 group 2 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair with multiple 
power options.