Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy. 
 
You asked the Plan to pre-approve a panniculectomy. The Plan denied your request. The Plan says this 
procedure is not medically necessary. 
 
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 panniculectomy. Our reviewer says 
that the requested panniculectomy is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the record indicates that the enrollee has an excessive pannus with localized 
adiposity and erythema intertrigo following bariatric surgery in the distant past. The record provided does not 
clearly document functional limitations and there is no history of intertrigo refractory to medical therapy. The 
record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of 
the requested service. 
 
 
 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 panniculectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a panniculectomy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an X-ray of the hand (73120) provided on November 1, 
2021. 
 
You asked the Plan to pay for an X-ray of the hand. You say that you have provided records to support the 
services billed. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 an X-ray of the hand. Our reviewer says that the code at issue 
does not meet criteria for reimbursement. Our reviewer found that the provider is billing the technical component modifier on this claim and the professional component on a related claim. Both claims with the 
technical and professional component modifiers cannot be submitted for the same provider with the same Tax 
ID number. The review has determined that the records did not support the denied code was properly reported, 
with the appropriate modifiers, on the correct claims. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an X-ray of the hand have not been met. Therefore, we decided that the Plan 
does not have to pay for an X-ray of the hand (73120) provided on November 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (K0108, E2313, E2377), 
adductor pad hardware (E1028), adjustable headrest hardware (E1028), lateral pads (E0956), and a headrest 
(E0955) for an approved power wheelchair. 
 
You asked the Plan to pre-approve the power wheelchair features. You say that these features are medically 
necessary. The Plan denied your request. The Plan says the requested features exceed the enrollee's needs, and 
some are included with the base wheelchair package. 
 
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 power wheelchair features. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee resides in a nursing facility where there is assistance for care available at 
all times. The record does not show that the enrollee is unable to use the standard joystick controller. The 
headrest and padding hardware is included in the base wheelchair unit and is not separately coverable. Records 
do not show that custom pads or headrests are 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 power wheelchair features have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an expandable controller (K0108, E2313, E2377), adductor pad 
hardware (E1028), adjustable headrest hardware (E1028), lateral pads (E0956), and a headrest (E0955) for an 
approved power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Coflex device. 
 
You asked the Plan to pre-approve a Coflex device. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 Coflex device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Coflex device is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Coflex device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Coflex device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for SNF services provided from August 11, 2020, 
through May 1, 2021. 
 
You asked the Plan to reimburse you for SNF services. The Plan denied your request. The Plan says the appeal 
is untimely. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SNF services have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to reimburse you for SNF 
services provided from August 11, 2020, through May 1, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. 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 the enrollee's functional 
level 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: 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 the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care facility. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device. 
 
You asked the Plan to pre-approve the device. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the Vertiflex device is experimental and more research is needed. 
 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex Superion device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion, subcutaneous cardiac rhythm monitor, 
including programming (33285). 
 You asked the Plan to pre-approve a rhythm monitor. You say that you are part of a research study to monitor 
and reduce atrial fibrillation burden. The Plan denied your request. The Plan says you do not meet approval 
guidelines. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve a rhythm monitor as part of a clinical trial. The Plan does not 
cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have 
to pre-approve an insertion, subcutaneous cardiac rhythm monitor, including programming (33285).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on October 6, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. 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 chest x-ray rendered on October 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve POV, group 1 standard, patient weight capacity up to 
and including 300 pounds (CPT code K0800). 
 
You asked the Plan to pre-approve the POV. You say that you cannot feel your feet, you fall to the side when 
using the walker, the cane you have is useless, you are diabetic, and have arthritis in most of your body. The 
Plan denied your request. The Plan says a wheelchair was recommended for use in the community and your 
home is not accessible to a POV. The Plan states they do not have evidence that a POV will greatly improve 
your ability to perform ADLs/MRADLs. 
 
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 POV. Our physician reviewer found 
the documentation does not support that you plan or require the use of the POV in the home. Additionally, 
there is no indication the POV will fit into the home for use. The requested POV is not medically necessary to 
accomplish mobility-related self-care tasks. 
 
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 POV have not been met. Therefore, we decided that the Plan does not have 
to pre-approve POV, group 1 standard, patient weight capacity up to and including 300 pounds (CPT code 
K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bioimpedance spectroscopy assessment (CPT 93702). 
 
You asked the Plan to pre-approve a bioimpedance spectroscopy assessment. The Plan denied your request. 
The Plan says a bioimpedance spectroscopy assessment is experimental/investigational. 
 
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 bioimpedance spectroscopy 
assessment. Our reviewer says that the requested bioimpedance spectroscopy assessment is not considered 
medically reasonable and necessary in this case. Our physician reviewer found currently available studies were 
reviewed and although they suggest successful early detection of initial stages of lymphedema, there is 
insufficiently high-quality data to clearly show clinically significant improved outcomes with 
ImpediMed L-Dex compared to standard screening methods to justify this request. Therefore, this request for 
bioimpedance spectroscopy will be considered not 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 a bioimpedance spectroscopy assessment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a bioimpedance spectroscopy assessment (CPT 93702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture and manual therapy provided on January 27, 
2022. 
 
You asked the Plan to pay for acupuncture and manual therapy. You say that the billed codes are consistent 
with acupuncture and the provider is a licensed acupuncturist. The Plan denied your request. The Plan says the 
services provided are not covered chiropractic services.  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 rules also say that acupuncture treatments may 
be provided by a physician in accordance with state requirements, or by physician assistants, nurse 
practitioners/clinical nurse specialists, and auxiliary personnel if they meet certain licensure requirements. 
 
The records show that the service at issue is not manual manipulation of the spine to be considered a covered 
chiropractic service and a licensed acupuncturist is a non-covered provider type. Therefore, we decided that the 
Plan does not have to pay for acupuncture and manual therapy provided on January 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
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. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 criteria for coverage are not met. Our physician reviewer found the records show that you do not have 
severe neuromuscular disease or are not able to stand up from a regular armchair or any chair in the home. The 
criteria for coverage are not met and the seat lift mechanism is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a seat lift mechanism.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of extra skin and tissue of arm 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the notes do not show any medical problems related to the extra arm skin. 
 
The Plan must follow Medicare rules. Medicare rules say that reconstructive surgery is performed on abnormal 
structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, 
involutional defects, or disease. 
 
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 not considered medically reasonable and necessary in this case. Our physician reviewer 
found the record indicates that the enrollee has had weight loss after hiatal hernia repair.  The record provided 
does not indicate functional impairment due to excessive arm skin nor the presence of rashes or intertrigo 
refractory to conservative medical management. The elements of the coverage criteria are not satisfied.  
 
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 removal of extra skin and tissue of arm
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDX testing provided on October 7, 
2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this testing is not 
medically necessary. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the requested testing is for 324 genes, many of which are not directly related to the type of cancer 
and potential treatment options for this enrollee and would be useless in clinical decision making. As this test 
includes medically unnecessary tests, the FoundationOne CDX will be considered not 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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the FoundationOne CDX testing provided on October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. The Plan denied your request. The Plan says 
the Plan does not see that the enrollee had imaging studies that show disc or bone problems at the same level. 
 
The Plan follows Medicare rules. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an epidural steroid injection. Our 
reviewer says that an epidural steroid injection is not medically necessary. Our physician reviewer found that 
there are no imaging studies that show disc or bone problems at the same level. Epidural steroid injections are 
supported when advanced imaging shows evidence of central disc herniation, osteophytes, or severe 
degenerative disc disease causing foraminal or central spinal stenosis. The clinical information provided does 
not describe this type of pain and, therefore, the requested procedure is not indicated at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.