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

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. 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 the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has chronic obstructive 
pulmonary disease (COPD) and chronic chest congestion. There is no diagnosis of cystic fibrosis, 
bronchiectasis, or neuromuscular disease. Medicare does not cover this device for COPD because there is inadequate evidence of safety and effectiveness for this diagnosis. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upper extremity prosthesis, not otherwise specified 
(L7499). 
 
You asked the Plan to pre-approve the prosthesis. You say that you are appealing the denial for a partial hand 
prosthesis. The Plan denied your request. The Plan says the left myoelectric partial hand prosthesis with 
independent finger exceeds the enrollee's needs 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 the prosthesis. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a partial hand prosthesis (iDigits Quantum) is not medically reasonable and necessary for the 
enrollee in this case The requested iDigits Quantum is not in widespread use for this enrollee's condition and 
exceeds the enrollee's needs. There is insufficient literature on the long-term outcomes on the effectiveness of 
this device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the prosthesis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the upper extremity prosthesis, not otherwise specified (L7499).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the medical records provided support the 
need for the requested IRF admission. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollee's condition they do not meet all the requirements for 
admission. 
 
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 appears to be improving and should only require short-term additional 
acute care services that can safely be provided at the current facility until more appropriate for a lower level of 
care soon. The enrollee does not require services at the LTACH that are not available and covered at the current 
facility. 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 the LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy services. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that this is for your well-being 
as you are suffering from cirrhosis of the liver. The Plan denied your request. The Plan says you do not meet 
criteria for the requested services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutrition therapy services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 05, 2021, 
through November 07, 2021, and billed with diagnosis code A41.9. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis A41.9 is supported by the records. The Plan denied your request. The Plan says the documentation 
submitted does not support primary diagnosis of A41.9. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with primary diagnosis code A41.9-sepsis, unspecified 
organism. 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 inpatient hospital services at the 
DRG originally billed. Our reviewer says that the documentation does not support the primary diagnosis of 
A41.9, Sepsis. Our physician reviewer found there was no leukocytosis and serum lactate were normal. The 
member has chronic thrombocytosis with a platelet count of 1,484. Creatinine and total bilirubin levels were 
normal. No oxygen was delivered, and the member remained on room air according to the respiratory flow 
sheets. The member's blood pressures were transient and responded to intravenous fluid, therefore primary 
diagnosis code A41.9-sepsis, unspecified organism is not an appropriate primary diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on November 05, 2021, through November 07, 2021, and billed with 
diagnosis code A41.9.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 14,2021, 
through December 18, 2021, and billed with diagnosis code N39.0. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis N39.0 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of N39.0. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code N39.0- (Urinary tract 
infection (UTI), site not specified). 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 inpatient 
hospital services at the DRG originally billed. Our reviewer says that the documentation does not support the 
secondary diagnosis of N39.0, Urinary tract infection, site not specified. Our physician reviewer found based 
on the reported symptoms not including dysuria, urinary frequency, or abdominal/pelvic discomfort, clinically 
the member did not have signs of UTI, regardless of the urinalysis and urine culture showing evidence of 
bacteria, which could have been contamination or colonization. Therefore, secondary diagnosis N39.0, Urinary 
tract infection, site not specified remains unsupported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on December 14,2021, through December 18, 2021, and billed with 
diagnosis code N39.0.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Group 2 power wheelchair (K0822). 
 
You asked the Plan to pre-approve the power wheelchair. You say that you are appealing the decision to deny 
the authorization. You need a power chair for independent mobility. The Plan denied your request. The Plan 
says the records do not support that the enrollee meets the requirements for approval. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, there is no standard written order prescribing a 
power wheelchair, there is no evidence of a home evaluation, and the records do not show that you have had a 
face-to-face encounter within the last 6 months. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pre-approve 
the Group 2 power wheelchair (K0822).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance and copayment for a tildrakizumab injection 
and administration provided on September 7, 2022. 
 
You asked the Plan to waive the coinsurance and copayment for the injection and administration. You say that 
you thought the Plan was supposed to cover expenses not paid by Medicare. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs and a $370 copayment for outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers.  
 
 You have been asked to pay a 20% coinsurance for the injection. This item/service falls within the Medicare 
Part B prescription drugs benefit category. You have also been asked to pay $87.55 for the administration, 
which is less than the $370 copayment per the EOC. This item/service falls within the outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers 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 coinsurance and copayment for a tildrakizumab injection and 
administration provided on September 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 17, 2021, 
to September 27, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed properly and should be paid. The Plan denied your request. The Plan says the documentation 
does not support the code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code I50.23, described as acute 
on chronic systolic (congestive) heart failure. 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 
inpatient hospital services at the DRG originally billed. Our reviewer says that the documentation does not 
support I50.23. Our physician reviewer found upon examination, the enrollee's lungs were clear and there was 
no evidence of jugular vein distension. No active need for diuresis was mentioned. Chest imaging revealed no 
appreciable pulmonary edema without acute findings. The enrollees presenting shortness of breath and chest 
pressure were in the setting of a non-ST-elevation myocardial infarction. There was no evidence of acute 
decompensation in the documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on September 17, 2021, to September 27, 2021, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the spinal canal 
and contents (72157) provided on May 2, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the MRI. You say that you would like this claim to be processed The Plan denied 
your request. The Plan says services from non-participating providers are not covered under the Plan unless 
pre-authorized. 
 
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 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 magnetic resonance imaging (MRI) of the 
spinal canal and contents (72157) provided on May 2, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 32555 billed for date of service July 26, 
2022. 
 
You asked the Plan to pay for procedure code 32555. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 32555 is bundled into payment for code 
71045. 
 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 32555 
is a column II code to column I code 71045. 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 32555 billed for date of service July 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 power wheelchair (K0800). 
 
You asked the Plan to pre-approve a power wheelchair. You say that you cannot go shopping and go long 
distances with a cane or walker. The Plan denied your request. The Plan says scooters that are used outside is 
not medically necessary and cannot be approved. 
 
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.  
 
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs and your 
condition can be improved by a walker, cane or manual wheelchair. The scooter is also being requested for 
outside use and for going out long distances. This means that Medicare rules for coverage of a PMD have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Group 1 power wheelchair 
(K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Sleep Number Split King C 360 Smart Bed. 
 
You asked the Plan to pre-approve these services. You say that you are willing to do a sleep study or any 
testing to show the bed will provide health benefits. The Plan denied your request. The Plan says the item is not 
covered. 
 
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 Sleep Number Split King C 360 Smart Bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0823) and retractable 
joystick (E1028). 
 
You asked the Plan to pre-approve the power wheelchair. You say that you would like to appeal the denial you 
need the wheelchair for your everyday activities and feel that it is medically necessary for you. The Plan denied 
your request. The Plan says the current power wheelchair meets the enrollee's current mobility needs and there 
is lack of indicated need for replacement of the current Group 2 power wheelchair. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a Group 2 power wheelchair. a Group 2 power wheelchair serves the same 
purpose as the power wheelchair. Therefore, we decided that the Plan does not have to pre-approve a Group 2 
power wheelchair (K0823) and retractable joystick (E1028).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 
16, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the claim was billed properly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service November 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you believe the denial of the Intracept 
procedure is unwarranted and unsupported by the enrollee's current medical status and current peer-reviewed 
literature. The Intracept procedure is medically necessary and supported by strong science. The Plan denied 
your request. The Plan says this procedure is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Intracept procedure (64628).