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

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested portable oxygen concentrator is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 oxygen concentrator Our 
reviewer says that the documentation does not support that the requested portable oxygen concentrator is 
medically reasonable or necessary. Our physician reviewer found you have a diagnosis of chronic respiratory 
failure with hypoxia. You use supplemental oxygen. The provided records document difficulty and 
inconvenience with your portable oxygen tanks. The supplied medical records do not document that the 
portable oxygen tanks do not meet your medical needs in your home. Therefore, you do not meet criteria for 
the requested device. 
 
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 portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 7, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed until September 29, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on June 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nonsterile gloves (A4927), provided on September 6, 
2022. 
 
You asked the Plan to pay for incontinence supplies. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for the nonsterile gloves (A4927), 
provided on September 6, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex Faspro. 
 
You asked the Plan to pre-approve Darzalex Faspro. You say that the requested drug is the better choice for the 
enrollee's advanced age. The Plan denied your request. The Plan says the enrollee does not have any stated 
contraindications to the preferred products. The Plan says that the enrollee has not tried any of the preferred 
agents and that the provider did not supply a rationale for use of the non-preferred product for safety or 
efficacy.  
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Darzalex Faspro. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the enrollee has multiple 
myeloma.  The requested medication is a new start.  The provided records do not indicate that the enrollee has 
tried and failed the Plan's preferred step one alternatives of bortezomib or Velcade. The record does not 
indicate that the enrollee has a contraindication to, or would have an adverse effect from, the Plan's preferred 
step one alternatives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Darzalex Faspro have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Darzalex Faspro.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual therapy (97140) and the therapeutic exercises 
(97110) provided from April 14, 2022, through September 12, 2022. 
 
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 these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the manual therapy (97140) and the therapeutic exercises (97110) 
provided from April 14, 2022, through September 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve scaling in presence of generalized moderate or severe 
gingival inflammation (D4346). 
 
You asked the Plan to pre-approve scaling in presence of generalized moderate or severe gingival inflammation 
(D4346). You say that you received a denial from the dental provider. The Plan denied your request. The Plan 
says scaling in moderate or severe gingival inflammation (D4346) is not covered under your benefit plan per 
the EOC. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
scaling in presence of generalized moderate or severe gingival inflammation (D4346).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a 
right total shoulder arthroplasty and will need inpatient admission after surgery. The Plan denied your request. 
The Plan says there is no documentation provided to support the expectation the enrollee will require a greater 
than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   

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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee is approved for a right total shoulder arthroplasty. The record 
does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or 
more midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 12, 2020, 
through July 13, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plans 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 pay for these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the hospital with a perirectal abscess requiring a bedside incision 
and drainage with intravenous antibiotics. The computed tomography (CT) scan provided did not show concern 
for a fistula or deep extension of infection of the area. There was no reported complication related to the 
procedure, and the cavity was packed with gauze and treated with basic wound care. The enrollees vital signs 
were stable and he was planned for discharge the next day. Observation status would have been sufficient for 
this brief and low complexity care. The enrollee was stable and not expected to require hospital care that would 
likely cross two midnights. 
 
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 pay for the acute inpatient hospital care provided from July 12, 2020, through July 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81455) provided on September 5, 2022. You asked the Plan to pay for laboratory testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says insufficient documentation was provided to support the medical necessity of 
these 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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory testing have been met. 
Specifically, the records provided do not include any progress notes from the enrollee's treating physician to 
support the medical necessity of this test. Therefore, we decided that the Plan does not have to pay for 
laboratory services (81455) provided on September 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (93000) provided on November 4, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code it not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 93000 is "Electrocardiogram, routine ECG with at least 
12 leads; with interpretation and report". 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 93000 is 
not supported by the records provided. Our reviewer found that the medical record includes documentation of 
left wrist x-ray, spine cervical x-ray, and skull x-ray 2 view. The medical record does not include 
documentation of a routine electrocardiogram (ECG) with at least 12 leads, and therefore the billed code cannot be verified. 
 
We looked at this coder'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 pay for the services (93000) provided on November 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the enrollee has been severely burned and has bad 
lungs. You say that the requested item will help treat the enrollee's condition. The Plan denied your request. 
The Plan says the requested ventilator will be set in average volume-assured pressure support (AVAPS) mode 
with auto-expiratory positive airway pressure (EPAP), which could be delivered by bi-level positive airway 
pressure (BiPAP) and therefore is non-covered. 
 
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 ventilator. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the record indicates that the enrollee has 
chronic respiratory failure from chronic obstructive pulmonary disease. The record does not document a trial and failure of BiPAP with back up rate and AVAPS.  The provided primary source documentation does not 
contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee 
could be treated with a BiPAP machine with AVAPS capability.   
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93882 billed for date of service September 
11, 2022. 
 You asked the Plan to pay for procedure code  93882. You say that the services should be covered due to 
medical necessity The Plan denied your request. The Plan says this code is included in the facility payment and 
is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code 93882. This means there 
is both a professional and technical component for the CPT code. In this case, an appropriate modifier to 
indicate the professional component has not been billed with CPT code 93882. Based on this information, we 
decided that Medicare rules for coverage of procedure code 93882 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 93882 billed for date of service September 11, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous 24 hour, 7 day per week private duty 
nursing. 
 
You asked the Plan to pre-approve continuous 24 hour, 7 day per week private duty nursing. You say that the 
services are necessary. The Plan denied your request. The Plan says 35 hours per week of nursing care and 10 
hours per week of health aide services have been approved already. The requested services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of continuous 24 hour, 7 day per week private duty nursing have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continuous 24 hour, 7 day per week private duty nursing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265) and side rails 
(E0305). 
 
You asked the Plan to pre-approve the items. You say that you need a full electric bed because you are unable 
to operate the crank on a semi-electric bed. The Plan denied your request. The Plan says the items are not 
covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the items have not been met. The rules say that a total electric 
hospital bed (E0265) is not covered; the height adjustment feature is a convenience feature. Total electric beds 
will be denied as not reasonable and necessary. Furthermore, side rails (E0305) are covered when they are 
required by the beneficiary's condition and they are an integral part of, or an accessory to, a covered hospital 
bed. The side rails are not covered because the total electric hospital bed is not covered. Therefore, we decided 
that the Plan does not have to pre-approve a total electric hospital bed (E0265) and side rails (E0305).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the services 
are medically necessary. The Plan denied your request. The Plan says an IRF 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 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 you do not have any complex functional deficits or active medical issues. Your 
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), an electronic 
connection between wheelchair controller and two or more power seating system motors (E2311), a harness 
(E2313), an expandable controller (E2377) and elbow support, armrest option (K0108x2). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the requested wheelchair with the seat 
functions is 100% medically necessary for the enrollee to function out of bed. Without this wheelchair, the 
enrollee will be forced to stay in bed which will lead to further illness, including pneumonia and pressure ulcer, 
and dramatically increase his chances of mortality. The Plan denied your request. The Plan says the request for 
armrest options, elbow support is miscoded and unbundled. The Plan also says the seat elevator does not serve 
a primary medical purpose and is statutorily non-covered. The Plan also says although there are three 
requested power options (tilt, recline and elevating leg rests), there is not a medical need to control these power 
options through the joystick. 
 
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.  
 
Medicare rules shows that a power seat elevation system is not covered because they are not primarily medical 
in nature. Medicare rules also show that power options such as an electronic connection between the 
wheelchair controller, the harness, and the expandable controller, do not have a medical need to control these 
power options through the joystick. The LCA confirms that the request for armrest options is miscoded and 
already included with the approved power tilt and recline system (E1007). This means that Medicare rules for 
coverage of additional wheelchair accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system (E2300), an electronic connection between wheelchair 
controller and two or more power seating system motors (E2311), a harness (E2313), an expandable controller 
(E2377) and elbow support, armrest option (K0108x2).