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

 
We decided that the Plan does not have to pre-approve the PMD. 
 
You asked the Plan to pre-approve the PMD. You say that the PMD is necessary. The Plan denied your request. 
The Plan says the clinical documents show that you have not seen the doctor for the request of a mobility 
scooter, and you will need to be evaluated by an occupational therapist beforehand. The Plan states you have 
been referred to the occupational therapist, but the records do not show you have had the required visit. 
 
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 PMD. Our physician reviewer found the documentation does not support that you have a mobility deficit that impairs MRADLs in the home 
and this mobility limitation is not ameliorated by a walker, cane, manual wheelchair. The documentation does 
not reveal a home assessment to support that the requested device will be able to safely maneuver in the home 
and access rooms for MRADL participation. The documentation does not support that the scooter will 
significantly improve your ability to participate in MRADLs and you will use it in the home. The 
documentation does not reveal the evaluation requested by the physician for a occupational therapy (OT) to 
evaluate the need for the scooter. The physician documentation does not reveal a face to face. The 
documentation does not reveal that the requested motorized scooter is medically necessary per LCD L33789. 
 
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 PMD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the PMD.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the special power wheelchair (group 3 power 
wheelchair) with two (2) or more power seat options (power recline and power seat elevation (CPT code(s): 
K0861, E2377, E2313, E1028, E2323, E1004, E2300, E2361, E2609, and E2617). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not 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 DME. Our physician reviewer 
found the requested Group 3 power wheelchair with multiple power options is not medically necessary per the 
LCD Power Mobility Devices (L33789) and Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-03, Medicare NCD Manual, Section 280.3(B). You have a Group 3 qualifying 
diagnosis of a neurological condition. The documentation indicates you have a mobility deficit that impairs 
MRADLs in the home and cannot be overcome with a manual wheelchair, walker, or cane due to pain and 
weakness and safety issues. While you may be able to safely use the requested wheelchair the documentation 
does not reveal that the requested chair with multiple power options is medically necessary. The documentation 
does not reveal that you use a ventilator attached to a wheelchair, are at high risk for development of a pressure 
ulcer (Braden score was mild risk). There is no evidence of intermittent catheterization. The physician 
documentation does not indicate objective evidence of spasticity on a BLE physical exam that needs a power 
seating system for management therefore the request for power recline exceeds your medical needs. You do not 
require a drive control interface other than a hand or chin-operated standard proportional joystick (examples 
include but are not limited to head control, sip and puff, switch control). The request for a Group 3 power 
wheelchair with multiple accessories exceeds your medical need. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the special power wheelchair (group 3 power wheelchair) with two (2) or more power seat 
options (power recline and power seat elevation (CPT code(s): K0861, E2377, E2313, E1028, E2323, E1004, 
E2300, E2361, E2609, and E2617).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve out of network (OON) dermatology services. 
 
You asked the Plan to pre-approve the OON dermatology services. You say that your current dermatologist 
does not have the equipment needed to treat you. You say that you cannot commute to Seattle due to medical 
conditions. The Plan denied your request. The Plan says the treatment required can be performed in network 
and there is public transportation available to this provider's location. The Plan says that there is also has 
coverage for 8 round trip transportation trips per year. The Plan says that there is no medical reason to 
authorize out of network care. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollees home. The Plan says that enrollees must use contract providers.  
 
The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located 
within reasonable distance and travel time from your home who can provide dermatology services and Mohs 
treatment. Under Medicare rules, this means that contract providers are accessible to you. Therefore, we 
decided that the Plan does not have to pre-approve out of network (OON) dermatology services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214), gloves (A4927) and specimen 
handling (99000) for the COVID-19 test provided on April 6, 2021. You asked the Plan to pay for the office visit, gloves and specimen handling. You say that the only service you 
received was a drive thru COVID-19 test and there is no record of you being a patient there. You say that you 
received approval prior to the test and the appeal should be reconsidered. The Plan denied your request. The 
Plan says the documentation provided does not support CPT code 99214. The Plan also says that CPT codes 
A4927 and 99000 are not reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT code 99211 should be used when office 
clinical staff furnish assessment of symptoms and specimen collection incident to the billing professionals 
services for both new and established patients. The rules say that non-contract providers must accept as 
payment in full payment amounts applicable in Original Medicare. 
 
We looked at the file and Medicare rules. The provider in this case used code 99214 to report the evaluation 
provided prior to COVID testing. Per the Medicare guidance, if the evaluation is solely for obtaining a COVID 
test, CPT code 99211 should be used. There is no evidence that evaluation beyond what was necessary to 
determine the need for this testing was performed. In addition, code 99000 has a status indicator of B in the 
Medicare Physician Fee Schedule, meaning that payment for this service is bundled with payment for other 
rendered services. Lastly, the code used to report the gloves utilized by the provider is for 100 gloves. This 
code would be billing for more supplies than were reasonably used during this encounter. In summary, the 
codes used to report the services related to the COVID testing were not appropriate. As a Medicare provider, 
you should not be billed for these services. Based on this information, we decided that Medicare rules for 
coverage of the office visit, gloves and specimen handling have not been met. Therefore, we decided that the 
Plan does not have to pay for the office visit (99214), gloves (A4927) and specimen handling (99000) for the 
COVID-19 test provided on April 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat lumbar epidural steroid injection for the 
enrollee. 
 
You asked the Plan to pre-approve the repeat injection. You say that this is medically necessary. The Plan 
denied your request. The Plan says there were no further records regarding pain and duration submitted by the 
treating physician. 
 
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 the repeat injection. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no record showing that the enrollee received 50% pain relief lasting at least three (3) 
months from the last injection. The review has determined that there is no documentation provided indicating 
that the first injection significantly improve the enrollee's condition. The review has determined that the 
requested service is not medically reasonable or necessary. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the repeat injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a repeat lumbar epidural steroid injection for the enrollee.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit for the evaluation and 
management of a patient (CPT code 99283) provided on April 26, 2021. 
 
You asked the Plan to pay for the emergency department visit. You say that the claim is billed with a valid and 
payable diagnosis code. The Plan denied your request. The Plan says the claim did not include the appropriate 
primary or first-listed or diagnosis which is based on the 2021 ICD-10-CM Manual. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 The primary diagnosis code listed on this claim is T26.91XA. Per ICD-10 guidelines, this diagnosis code has a 
code first note meaning that an underlying condition must be sequenced first. It is not appropriate to list 
diagnosis code T26.91XA as the primary diagnosis on the claim. Based on this information, we decided that 
Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that 
the Plan does not have to pay for the emergency department visit for the evaluation and management of a 
patient (CPT code 99283) provided on April 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an inpatient hospital stay provided from 
October 3, 2021, to October 20, 2021, and from November 5, 2021, to November 15, 2021. 
 
You asked the Plan to waive the copayments for an inpatient hospital stay. You say that you were previously 
diagnosed with COVID-19 therefore you should have qualified for federal COVID-19 relief funds. You also 
say that it is your understanding that there were federal COVID-19 relief funds available until September of 
2021. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $325 
copayment per day for days 1-6 for an in-network inpatient hospital stay. The contract also says that there is a 
$0 copayment for additional days after day 6. According to the Plan, the emergency relief for out-of-pocket health plan costs expired on September 30, 2021. 
You have been asked to pay a total of $1,950, which is a $325 per day for days 1-6 for an inpatient hospital 
stay from October 3, 2021, to October 20,2021 ($325 copayment x 6 days = $1,950). You have also been asked 
to pay a total of $1,950, which is a $325 per day for days 1-6 for an inpatient hospital stay from November 5, 
2021, to November 15,2021 ($325 copayment x 6 days = $1,950). There is no charge for additional days after 
day 6. An inpatient hospital stay falls within the Inpatient Hospital Care 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 copayments for an inpatient hospital stay provided from October 3, 2021, to 
October 20, 2021, and from November 5, 2021, to November 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power mobility device. You asked the Plan to pre-approve the requested device. You say that the device is necessary to improve the 
enrollee's quality of life. The Plan denied your request. The Plan says the enrollee does not meet criteria. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices are only covered under 
certain medical indications.  
 
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 requested device. Our physician 
reviewer found that the documentation does reveal that the enrollee has a mobility deficit that impairs 
MRADLs in the home. The documentation is not clear that he is unable to use a manual wheelchair in the home 
for MRADLS due to forearm ulcers. There are no objective findings of this on an objective physician exam.  
While he may have the cognition to safely operate the power wheelchair, the documentation does that the 
bathroom is not accessible. There is no evidence that he is making home modifications. As the documentation 
does not indicate that the wheelchair will fit in the bathroom it is not clear that the requested device will be able 
to safely maneuver in the home and access all rooms for MRADL participation. The documentation does not 
reveal that the requested device is medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power mobility device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple 
power options. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 3 PWC is covered when specific criteria 
are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
Parkinson's disease and a mobility deficit that impairs the completion of mobility-related activities of daily 
living (MRADLs) in the home). The records do not show that the enrollee is at high risk for the development of 
pressure ulcers, uses intermittent catheterization for bladder management, or has objective evidence of 
spasticity on a bilateral lower extremity physical exam that requires a power seat system. The request for the 
power tilt and recline is therefore not medically necessary. The enrollee also does not require a ventilator or 
drive control interface. The Group 3 PWC with multiple power options is not reasonable or medically 
necessary, as it exceeds the enrollee's needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 3 power wheelchair (PWC) with multiple power options.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an emergency response system (S5161). 
 
You asked the Plan to pre-approve an emergency response system. You say that you live alone and there are a 
lot of times that you are alone in your home. The Plan denied your request. The Plan says an emergency 
response system is not medically necessary. 
 
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 an emergency response system (S5161).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care visits provided from March 22, 
2021, to June 14, 2021. 
 
You asked the Plan to waive the copayment for the wound care visits. You say that the services should be 
covered in full as you feel they were coded incorrectly. The Plan denied your request. The Plan says the cost-
sharing applied correctly based on the services provided. 
 
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 $325 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $3,284.52 copayment for 11 wound care visits, these services are considered 
surgical procedures and were performed in an outpatient hospital setting. 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 wound care visits provided from March 22, 2021, to June 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request cannot be authorized at this time. 
 
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 transient right sided weakness and aphasia. 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 medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90832), provided on November 22, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy. You say that the services are medically necessary. The Plan 
denied your request. The Plan says non-emergent services must be provided 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 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 the psychotherapy (90832), provided on 
November 22, 2021 by an out-of-network (OON) provider.