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

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with Single Power 
Option represented by code K0856 and related accessories represented by codes E2361, E1028, E1002, E2620, 
E0955, E1028, E2310, and E2607. 
 You asked the Plan to pre-approve the Group 3 PWC with Single Power Option and related accessories. You 
say that the records provided support the need for the items in dispute. The Plan denied your request. The Plan 
says the enrollee does not have a medical need for single power option included with the requested wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC is covered for certain clinical 
indications. Medicare rules say that if the PWC base is not covered, then related accessories will be denied. 
 
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 3 PWC with Single Power 
Option and related accessories. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found the items in dispute exceed the enrollee's medical needs. The documentation does not 
reveal that the enrollee uses a ventilator attached to a wheelchair, is at high risk for development of a pressure 
ulcer, utilizes intermittent catheterization for bladder management, or needs a power seating system to manage 
increased tone or spasticity. Therefore, the request for power tilt exceeds the enrollee's medical needs. The 
E2310 Electro connect btw control is requested to control power tilt through the joystick. The notes state that 
these are needed when 1 actuator is being used. The electrical connection between the wheelchair controller 
and one motor (E2310) is not medically necessary. As the power tilt is not medically needed the E2310 Electro 
Connect Btw 1 Sys cannot be approved. 
 
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 3 PWC with Single Power Option and related accessories have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair 
(PWC) with Single Power Option represented by code K0856 and related accessories represented by codes 
E2361, E1028, E1002, E2620, E0955, E1028, E2310, and E2607.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options and upgraded electronics (K0861, E2361, E2377, E2313, E2311, E1028, E1007, E2601a and E1012). 
 
You asked the Plan to pre-approve the power wheelchair. You say that you are appealing the denial for the 
power wheelchair requested for the enrollee. The Plan denied your request. The Plan says there are no clinical 
notes that indicate that the enrollee can use the requested group 3 power wheelchair safely and independently. 
 
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 power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee's mobility limitation is not due to a neurological condition, myopathy, or 
congenital skeletal deformity. The face-to-face documentation does not recommend a Group 3 power 
wheelchair but states a Group 2 power wheelchair is recommended. The documentation indicates the enrollee 
has dementia. The documentation is not clear that the enrollee can operate this wheelchair safely. The enrollee 
also has a caregiver around the clock for activities of daily living assist. The documentation does not support 
that the requested Group 3 wheelchair with accessories is required significantly improve her ability to perform 
mobility related activities of daily living in the home. 
 
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 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Group 3 power wheelchair with multiple power options and upgraded 
electronics (K0861, E2361, E2377, E2313, E2311, E1028, E1007, E2601a and E1012).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says treatment can 
safely be rendered in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
surgery services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laryngoscopy, bronchoscopy, and esophagoscopy (procedure 
codes 31535, 31622, and 43191) provided to the enrollee on November 22, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes cannot be verified. 
 
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 the denied codes is: 
 
CPT 31535: 
 
Laryngoscopy, direct, operative, with biopsy 
 
CPT 31622: 
 
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed (separate procedure) 
 
CPT 43191: 
 
Esophagoscopy, rigid, transoral; diagnostic, including collection of specimen(s) by brushing or washing when 
performed (separate procedure) 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that procedure code 43191 is not 
documented to be separate and distinct from procedure code 41120. Procedure code 31622 is not documented 
to be separate and distinct from procedure code 41120 as the area of the body was the same, and therefore not 
separate. Procedure code 35135 is not indicated by the medical records as there was no biopsy separately taken 
during the procedure. 
 
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 laryngoscopy, bronchoscopy, and esophagoscopy (procedure codes 31535, 31622, and 43191) 
provided to the enrollee on November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay more for a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on June 2, 2022. 
 
You asked the Plan to pay more for an evaluation and prophylaxis. You say that these services should be paid 
at 100%. The Plan denied your request. The Plan says that you are responsible for any charged amount above 
the Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide the correct Evidence of Coverage (EOC). Without the 
correct EOC we are unable to determine if the dental benefits were applied correctly. Therefore, we decided 
that the Plan has to pay more for a periodic oral evaluation (D0120) and prophylaxis (D1110) provided on June 
2, 2022.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (code 90832) provided on 
February 8, 2022. 
 
You asked the Plan to pay for code 90832. You say that these services were medically necessary and provided 
in good faith. The Plan denied your request. The Plan says the record does not document contact with the 
patient's attending or primary care physician. 
 
The Plan must follow Medicare rules. Medicare rules say that in order for clinical psychology services to be 
covered, there must either be a referral from the patient's primary care or attending physician or there must be 
evidence in the record that the clinical psychologist has consulted or attempted to consult with the patient's 
primary care or attending physician. If the patient consents to this consultation or declines consent, this must 
also be in the medical record.  
 
We looked at the medical records you submitted in this case. There is nothing in the medical record discussing 
consultation (or attempts to consult) with the patient's attending or primary care physician.  There is no evidence that the patient either agreed to or declined such consultation. Based on this information, we decided 
that Medicare rules for coverage of code 90832 have not been met. Therefore, we decided that the Plan does 
not have to pay for outpatient mental health services (code 90832) provided on February 8, 2022.
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 records provided support the necessity of the 
services in dispute. The Plan denied your request. The Plan says the request is not medically necessary under 
Medicare criteria. 
 
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 enrollees 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 chest pain and cardiac arrest and was transferred to skilled nursing on September 22, 2022. 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for hearing aids provided on  
February 2, 2022. 
 
You asked the Plan to pay an additional amount for hearing aids. You say that you were informed that you had 
$4500 out of pocket with a $35 copay and then covered in full and you were allowed to go anywhere for the 
hearing aids. The Plan denied your request. The Plan says the claim processed with the correct cost share. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the claim paid with the correct cost share. 
Therefore, we decided that the Plan does not have to pay an additional amount for hearing aids provided on 
February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower or sacral spine facet joint injection using imaging 
guidance, three levels (64495, 64494 and 64493). 
 
You asked the Plan to pre-approve the injection services. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says there is insufficient evidence 
that the requested service meets the reasonable and necessary standard for medical necessity. 
 
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 injection services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found it is medically reasonable and necessary to have diagnostic medial branch blocks 
performed. However, the LCD limits the number to just 2 levels. However, if prior injections were performed, 
then documentation must be submitted to clarify the effectiveness and duration of the pain relief achieved. 
 
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 injection services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lower or sacral spine facet joint injection using imaging guidance, three levels 
(64495, 64494 and 64493).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bathroom scale (A9270, S9999) purchased May 26, 
2022. 
 
You asked the Plan to pre-approve the bathroom scale. You say that your doctor recommended that you have a 
scale in order to remain compliant with your weight loss regimen and maintain weight loss goals so you can 
have the surgery. The Plan denied your request. The Plan says this 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 the bathroom scale (A9270, S9999) purchased May 26, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Via Disc Allograft. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you have chronic low back pain and 
have had injections, acupuncture, and physical therapy as well as pain relief drugs. The requested Via Disc 
Allograft is considered experimental/investigational in nature. The services are therefore 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 Via Disc Allograft.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 home health skilled nursing visits. 
 
You asked the Plan to pre-approve 7 home health skilled nursing visits. 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 home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 7 home health skilled nursing visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found provided 
records do not document any acute or unstable medical conditions or changes in medication or treatment which 
would necessitate any further skilled nursing visits beyond what have already been approved. Records 
document the enrollee/caregiver has been educated on his disease process and medications. No medical notes 
from the enrollee's treating physician are provided documenting an order or need for additional skilled nursing 
services beyond what have been approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 7 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 7 home health skilled nursing visits.
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 enrollee needs LTACH for vent 
weaning, is stable for transfer and the level of care cannot be rendered at a lower level of care. The Plan denied 
your request. The Plan says the enrollee is receiving appropriate inpatient acute care and is currently unstable 
for transfer to an LTACH. 
 
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 enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving care. All medically necessary care is being provided in 
the current acute care setting. 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 setting. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darbepoetin Alfa 200mcg/1mcg asp (200 x 13 + 2600 
units) for the enrollee. 
 
You asked the Plan to pre-approve the dosage. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested dose is above the recommended dose for patients over 18. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 dosage. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that the requested 
dose exceeds the guideline recommendations. Dosing of less than 0.45 mcg/kg is given no more frequently 
than every four weeks. The review has determined that the documentation does not support that this dose is 
medically reasonable and necessary for the patient. The documentation does not support that the dose is safe 
and effective for the patient. 
 
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 dosage have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Darbepoetin Alfa 200mcg/1mcg asp (200 x 13 + 2600 units) for the enrollee.