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

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided July 20, 2021. 
 You asked the Plan to pay for the orthosis. You say that the medical records provided will show proof of 
medical necessity. The Plan denied your request. The Plan says the documentation submitted did not 
sufficiently support the billed supply code 
 
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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation did not clearly support this request. There was no objective 
instability of the lower back or recent or planned surgery that might warrant temporary use of bracing. Low 
back pain was only listed without flare-up, and no signs of radiculopathy. Low back pain is not an appropriate 
indication alone for bracing. Therefore, this request for lumbar brace will be considered not medically. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the lumbar-sacral orthosis (L0650) provided July 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in shower. 
 
You asked the Plan to pre-approve a walk-in shower. You say that you have issues with balance. You have no 
feeling in your legs from neuropathy and have fallen several times. You need a handicap shower that will 
prevent you from falling. The Plan denied your request. The Plan says a walk-in shower is a household fixture 
that does not have a medical purpose and is considered a convenience item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in shower.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infection agent detection panel (code 0202U) provided on 
January 26, 2022. 
 
You asked the Plan to pay for the infectious agent detection panel. You say that this test is a comprehensive 
panel which allows better diagnostics for patients suspected of COVID-19. The Plan denied your request. The 
Plan says this test is not a covered service. The Plan must follow Medicare rules. Medicare rules say that 
Multiplex PCR respiratory viral panels of 6 or more pathogens are not covered.  The records show that the test 
you performed tested 22 different pathogens.  As a result, this test is covered for all indications. Therefore, we 
decided that the Plan does not have to pay for the infection agent detection panel (code 0202U) provided on 
January 26, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee does not have any parental 
medication; complex wound care or nutrition given via a feeding tube. She is medically stable without any 
acute exacerbations of chronic medical problems. Her physical function is at or near her baseline. Although 
further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled 
services can be provided at a lower level of care than a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate inpatient care at the current hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is improving and should only require short-term additional acute 
care services that can safely be completed at the current facility. Transfer to LTACH is not medically necessary 
as it would not be clinically advantageous. Completion of treatment at the current facility is recommended. 
 
 
  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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous nerve stimulator (PNS) (64555). 
 
You asked the Plan to pre-approve a percutaneous nerve stimulator. You say that medical records have been 
submitted to show medical necessity. The Plan denied your request. The Plan says the requested procedure is 
unproven and 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 Percutaneous Nerve Stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the request is for placement of StimQ in proximity to the cluneal nerves. 
This is considered experimental/ investigational therapy for low back pain. There is insufficient evidence of 
efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Percutaneous Nerve Stimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a percutaneous nerve stimulator (PNS) (64555).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care associated with 
laparoscopy fundoplasty. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee requires inpatient 
care after the procedure is performed. The Plan denied your request. The Plan says pre-operatively, the 
intensity for an acute inpatient level of care is not met. 
 
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 payment are met in this case. Our physician reviewer found that the clinical documentation does not support poorly controlled co-
morbid conditions which would prevent the enrollee from having this elective surgical intervention. The 
requested procedure code is not on the Inpatient Only list; therefore, inpatient admission cannot be approved 
The review has determined that the record does not show that at the time of inpatient admission the admitting 
physician would reasonable expect that the enrollees necessary hospital care (including earlier emergency 
department and/or observation care) would span 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care associated with laparoscopy fundoplasty.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fifty (50) additional routine transportation trips 
(A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you are requesting 
reconsideration for the denied services. The Plan denied your request. The Plan says you have used 38 out of 
the allotted 36 one-way trips approved per year. You have 0 trips remaining; therefore, your benefit has been 
exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve fifty (50) additional routine transportation trips (A0120).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided June 10, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that you were provided assistance after a fall 
and declined a trip to the hospital. The Plan denied your request. The Plan says this service is not covered when 
there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 The ambulance company did not provide transport services on June 10, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided June 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued inpatient admission from August 3, 2022, 
forward. 
 
You asked the Plan to pre-approve a continued inpatient admission. You say that the enrollee needs continued 
inpatient care. The Plan denied your request. The Plan says the enrollees current treatment does not meet 
Medicare guidelines for continued inpatient care as care can be safely given at a lower level of care. 
 
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 continued inpatient admission. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the review indicates that as of August 3, 2022, care can be provided in 
alternate setting. The enrollee is currently receiving oral medications and routine wound care. The enrollee 
appears clinically stable.  
 
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 continued inpatient admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a continued inpatient admission from August 3, 2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and treatment 
of root canal obstruction (D3331) to be provided by an Endodontist. 
 
You asked the Plan to pre-approve dental services. You say that you are in a lot of pain, you cannot talk, you 
cannot eat and you stopped taking medication because it bothers your stomach. The Plan denied your request. 
The Plan says the requested services are not a covered benefit with your Plan. The Plan also says services must 
be performed by a participating general dentist. Consults with other dental specialists are not covered. 
 
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. The EOC confirms that services must be performed by a participating 
general dentist. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral 
evaluation (D0150) and treatment of root canal obstruction (D3331) to be provided by an Endodontist.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77067 billed for date of service August 11, 
2021. 
 You asked the Plan to pay for procedure code 77067. You say that you do not believe this code should be 
bundled. The Plan denied your request. The Plan says payment for code 77067 is bundled into payment for 
code 77066. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 77067 
is a column II code to column I code 77066. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 77067 billed for date of service August 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unspecified removable prosthodontic procedure 
(D5899). 
 
You asked the Plan to pre-approve the procedure. You say that you need this service because you do not breath 
properly while sleeping. The Plan denied your request. The Plan says an unspecified removable prosthodontic 
procedure (D5899) is not covered by your routine dental benefits. 
 
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 an 
unspecified removable prosthodontic procedure (D5899).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 22, 2021, 
through June 25, 2021. 
 
You asked the Plan to pay for the home health services.. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim has not been submitted as 
required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that for submission of a request for anticipated 
payment (RAP), the home health agency (HHA) must submit within 5 calendar days after the start of care and 
within 5 calendar days after the "from date" for each subsequent 30-day period of care. As the RAP was not 
submitted within this timeframe, we decided that Medicare rules for coverage of the home health services. have 
not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided 
from June 22, 2021, through June 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost for the inpatient stay provided from September 17, 
2021, through September 29, 2021. 
 
You asked the Plan to reduce the cost for the inpatient stay. You say that you have an annual deductible of 
$6,700 but owe more than that. You say that the claim should be reviewed, and additional payment made. The 
Plan denied your request. The Plan says the claim reprocessed to apply the in-network copayment. 
 
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 $300 
copayment per day, for days 1-5, for each in-network Medicare-covered hospital stay.  
 
  You have been asked to pay a total of $1,500 for the inpatient stay ($300/day x 5 days = $1,500). The inpatient 
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 reduce the cost for the 
inpatient stay provided from September 17, 2021, through September 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of home health skilled services after 
August 3, 2022. 
 
You asked the Plan to pre-approve the continuation of home health skilled services. You say that this is 
medically reasonable and necessary. The Plan denied your request. The Plan says the rules for SNF care have 
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 the continuation of home health skilled 
services. Our reviewer says that the requested home health services are not medically reasonable and necessary. 
Our physician reviewer found that the documentation does not support that you require additional skilled 
nursing services or skilled rehab services to provide treatment that is medically necessary. You do not require 
additional skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to 
improve your condition, perform a maintenance program to maintain your condition and/or prevent 
deterioration. You have been medically stable without any recent exacerbation of chronic medical problems or 
hospitalizations. The requested home health services are 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 continuation of home health skilled services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the continuation of home health skilled services after 
August 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary for your condition. The Plan denied your request. The Plan says the criteria for a home ventilator 
have not been met. 
 
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 home ventilator. Our reviewer says 
that the requested home ventilator is not medically reasonable and necessary. Our physician reviewer found the 
record indicates that you have chronic respiratory failure from chronic obstructive pulmonary disease. The 
record indicates that you were hypercarbic and treated in bilevel positive airway pressure mode. The provided 
primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. You could be treated with a bilevel positive airway pressure machine with average 
volume-assured pressure support capability. The Plan has indicated such a device is available for coverage.  
The elements of the coverage criteria are not satisfied. The requested service cannot be recommended 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.