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

 
We decided that the Plan does not have to pre-approve power wheelchair with two (2) or more power seat 
options (power tilt, power recline and power seat lift). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the notes do not show that the enrollee has a medical need for these power options. The 
Plan states upgraded electronics (expandable controller, harness and electronics) cannot be covered per 
Medicare rules. The Plan states there is not a medical need to control more than two power options though the 
joystick and the seat lift does not serve a medical purpose and cannot be covered. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the DME. Our physician reviewer 
found there is no documentation that the group 3 power wheelchair with two (2) or more power seat options 
(power tilt, power recline, power elevating leg rests and power seat lift) at issue in this case meets Medicare criteria for medically reasonable and necessary. Provided records do not support that the enrollee is high risk 
for skin breakdown (the enrollee is currently walking with a cane), has a history of pressure ulcer(s) or has had 
skin flap surgery. Records do not document the patient has a musculoskeletal condition or the presence of a 
cast or brace which prevents 90-degree flexion at the knee; or the enrollee has significant edema of the lower 
extremities that requires an elevating leg rest. Records do not document the enrollee performs bladder self-
catheterization and is unable to transfer independently or that the enrollee has increased muscle tone or 
spasticity. The requested power seat elevation feature is statutorily non-covered as it serves no primary medical 
purpose. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve power wheelchair with two (2) or more power seat options (power tilt, power recline and power 
seat lift).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Gel-One injection (J7326) provided on October 29, 2020. 
 
You asked the Plan to pay for the injection. You say that this is necessary. The Plan denied your request. The 
Plan says the requested drug is not medically necessary. 
 
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 pay for injection. Our reviewer says that the Gel-
One injections are not medically necessary. Our physician reviewer found the provided documentation does not 
indicate that knee osteoarthritis has been confirmed with radiologic imaging. The documentation does not 
indicate the presence of knee pain that has failed conservative treatment with analgesics and/or non-
pharmacologic therapies. Therefore, the reviewer found that the injections are not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injection have not been met. Therefore, we decided that the Plan does not have 
to pay for the Gel-One injection (J7326) provided on October 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code(s): 22869 and 22870). 
 
You asked the Plan to pre-approve the surgery. You say that the service is medically necessary. The Plan 
denied your request. The Plan says unproven and not medically necessary procedures are not covered by 
Medicare due to insufficient evidence of efficacy. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Vertiflex 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 the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drugs or medicaments dispensed in the office for home use 
(D9630) provided on May 3, 2022. 
 
You asked the Plan to pay for medications dispensed in the office for home use. You say that this medication 
was necessary, and you do not understand why it is not covered by your policy. The Plan denied your request. 
The Plan says this service is not covered by your dental benefit. 
 
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 pay for drugs or 
medicaments dispensed in the office for home use (D9630) provided on May 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are very sick from cancer and radiation. You say 
that you require assistance with daily activities, and have fallen once in the hospital and broke your ankle. You 
do not have anyone who can assist you at your home. The Plan denied your request. The Plan says based on 
Medicare guidelines the inpatient rehabilitation facility services you are requesting do not meet the 
requirements for approval. 
 
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 you have a medical history including metastatic breast cancer who presented to 
the hospital with weakness and constipation. You have been diagnosed with recurrent falls and advancement of 
metastatic disease throughout your spine. You were also diagnosed with a minimally displaced left proximal 
fibula fracture. You have been treated conservatively and have remained medically stable. The most recent 
therapy notes indicate that you require minimal assistance for bed mobility and transfers. There are no complex 
nursing or rehabilitation needs. While you have a need for physical or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. 
 
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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 16, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
screening test. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2 units of procedure code 64483 billed for date of service 
February 7, 2022.  You asked the Plan to pay for 2 units of procedure code 64483. You say that the operative report supports the 
procedure was done and was medically necessary. You say that ambulatory surgical center providers are not 
allowed to use modifier 50 and payment is required. The Plan denied your request. The Plan says procedure 
code 64483 has an MUE value of 1 but 2 units were billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64483 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 2 units of 
procedure code 64483 have not been met. Therefore, we decided that the Plan does not have to pay for 2 units 
of procedure code 64483 billed for date of service February 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on March 3, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the service is 
not a separately reimbursed service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 76376 is 3D rendering with interpretation and reporting 
of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
postprocessing under concurrent supervision; not requiring image postprocessing on an independent 
workstation. 
 
We find that CPT code 76376 is a packaged service when billed under the hospital outpatient prospective 
payment system. The payment is packed into payment for other services, which means there is no separate 
payment.  Therefore, we decided that the Plan does not have to pay for the imaging services provided on March 
3, 2022.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the radiofrequency transmitter. We decided that the 
Plan does not have to waive the copayment for the neurostimulator implant insertion.  
 
You asked the Plan to waive the coinsurance for the implant insertion and radiofrequency transmitter. You say 
that the doctor informed you that there would be no charges for the procedure. The Plan says that the correct 
copayment and coinsurance were applied. 
 
We decided that the Plan has to waive the coinsurance for the radiofrequency transmitter.  
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). The Plan says that you must pay a 20% coinsurance for prosthetic 
devices. Based on the Plan contract, however, you cannot be asked to pay more than a 0% coinsurance for 
durable medical equipment (DME) items other than wheelchairs, walkers, scooters, hospital beds, spinal 
stimulators, and osteogenesis devices. Therefore, we decided that the Plan has to waive the coinsurance for the 
radiofrequency transmitter. 
 
We also decided that the Plan does not have to waive the copayment for the neurostimulator implant 
insertion. 
 
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 $250 
copayment for each visit to an ambulatory surgical center or outpatient hospital facility.  
 
You have been asked to pay a $250 copayment for the neurostimulator implant insertion. The implant insertion 
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 copayment for the 
neurostimulator implant insertion. 
 
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: 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 enrollee's recovery will be adversely affected if 
the IRF is not approved. The Plan denied your request. The Plan says based on Medicare guidelines, the 
requested IRF services do not meet the requirements for approval. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does not require an IRF stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy program. The enrollee continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that he would 
meet criteria for admission to an IRF. There is no indication that the enrollee would require skilled 
rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision of a 
physician with at least 3 visits weekly to regain or maintain his functional status. The enrollee can receive 
further services at a lower level of care. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you have not made any progress and that you need 
around the clock care. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there is no evidence that you require services that are not available at the current 
facility.  As such, transfer to another SNF is not medically necessary or reasonable. 
 
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 SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided February 7, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has 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 pay for the genetic testing. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records show no clear clinical rationale for the molecular testing that was 
performed. 
 
 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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for genetic testing (81479) provided February 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the panniculectomy (CPT code 15830). 
 
You asked the Plan to pre-approve the panniculectomy. You say that this would help with the rashes you have 
been getting. The Plan denied your request. The Plan says the medical documentation does not include 
photographs indicating that the panniculus hangs below the level of the pubis and does not include evidence 
that you have maintained a stable weight for at least six (6) months. 
 
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 panniculectomy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record provided is insufficient to determine the medical necessity of the requested 
service. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested 
service is not 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 panniculectomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the panniculectomy (CPT code 15830).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the continuous positive airway pressure (CPAP) device provided on 
April 1, 2022. 
 
You asked the Plan to pay for the CPAP device. The Plan denied your request. The Plan says that a prior 
authorization was not received. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The file shows that the service at issue was provided by a par-provider. The file does not show that the Plan 
provided notice that the CPAP device would not be covered. Under Medicare rules, this means the CPAP 
device is considered approved by the Plan. The file does show that the par provider was in error in not 
obtaining an authorization. You should not be held responsible for a par providers error. Therefore, we 
decided that the Plan has to pay for the continuous positive airway pressure (CPAP) device provided on April 
1, 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.