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

 
We decided that the Plan does not have to pre-approve a segmental pneumatic compression device (E0662, 
E0667, E0656).  
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the documents provided do not show objective pre-post measurements of the lower 
extremities and trunk over four weeks, to support a good faith trial with the basic pump before the request for 
an advanced pump. 
 
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 as the records do not document an adequate trial and failure of a standard pump, with regular, daily, 
multiple-hour home usage after careful, in-person fitting, training and supervision by a technician who is 
skilled in and who successfully uses the pump as required, it cannot be said that the enrollee has unique 
characteristics that would indicate the segmented pump over a standard pump. 
 
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 a segmental pneumatic compression device (E0662, E0667, E0656).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator (E0760). 
 
You asked the Plan to pre-approve an ultrasonic osteogenesis stimulator. You say that the requested device is 
medically necessary. The Plan denied your request. The Plan says the requested device does not meet Medicare 
criteria. 
 
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 an ultrasonic osteogenesis stimulator. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found provided records do not document nonunion of the fractures 
documented by a minimum of two sets of radiographs obtained prior to starting treatment with the osteogenesis 
stimulator, separated by a minimum of 90 days as required by the Local Coverage Determination: Osteogenesis 
Stimulators (L33796). Recent radiographs and a magnetic resonance scan show evidence of left rami fracture 
healing and callus formation. 
 
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 ultrasonic osteogenesis stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator (E0760).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift and a stair glide. 
 
You asked the Plan to pre-approve the items. You say that this is needed because of total disability. The Plan 
denied your request. The Plan says this is 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. Medicare rules also state that stair lifts are not covered because 
they are not primarily medical in nature. 
 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 items. Our reviewer says that the 
requested seat lift is not medically reasonable or necessary. Our physician reviewer found that in this case, the 
documentation does not indicate that you have severe neuromuscular disease, or that you are incapable of 
standing up from a regular armchair, or any chair in the home. 
 
We looked at this physician's review, the file, and Medicare rules. Our reviewer found that the seat lift is not 
medically necessary. Additionally, while a stair lift may be appropriate in this case, neither the Plan nor 
Medicare offers coverage of this item. Based on this information, we decided that Medicare rules for coverage 
of the items have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift and 
a stair glide.
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 IRF care is medically necessary. The 
Plan denied your request. The Plan says the requested IRF care does not meet 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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a 
reasonable expectation that the 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for physical therapy services rendered on 
January 6, 2022.  
 
You asked the Plan to waive the deductible for physical therapy services rendered on January 6, 2022. You say 
that you have already paid a $40 copayment for this service. The Plan denied your request. The Plan says you 
have a $300 combined in-network and out-of-network deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $300 combined in-network and out-of-network deductible which 
applies to Outpatient Rehabilitation Services.  
 
 The item or service you asked the Plan to waive the deductible for falls within the Outpatient Rehabilitation 
Services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that the 
$300 deductible applies to outpatient rehabilitation services. This cost sharing is a contractual obligation that 
had not been met at the time physical therapy was received on January 6, 2022. Contact the Plan regarding the 
amount still owed toward the deductible for this service. Therefore, we decided that the Plan does not have to 
waive the deductible for physical therapy provided on January 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 81403, 81404, 81405, 81406 
and 81479 provided December 7, 2021. 
 You asked the Plan to pay for the laboratory services. You say that please find the attached complete medical 
records along with W-9 form and process the claim and consider payment for the same as it is a medical 
necessity. The Plan denied your request. The Plan says evidence of misrepresented services. 
 
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. Upon outreach to the ordering provider's office, the Plan verified that 
there were no records that the denied tests were ordered by the ordering provider. Based on this information, 
we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we 
decided that the Plan does not have to pay for the laboratory services coded as 81403, 81404, 81405, 81406 and 
81479 provided December 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound rendered on January 24, 2022. 
 
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 services are not separately payable. 
 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 76705 
is a column II code to column I code 93976. 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 the abdominal ultrasound rendered on January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan must reduce the cost-sharing for the urgent care visit and the X-ray. We decided 
that the Plan does not have to waive the deductible for the walking boot.  
 
You asked the Plan to w lower the cost-sharing for an urgent care visit, x-ray, and walking boot. You say that 
you shouldnt have to pay the cost-sharing. The Plan says that the cost-sharing has been applied correctly. 
 
We decided that the Plan must reduce the cost-sharing for the urgent care visit and the X-ray.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $35 copayment for Urgently Needed Services. Cost-sharing for 
necessary urgently needed services furnished out-of-network is the same as for such services furnished in-
network. 
 
 The Plan says you must pay a 40% coinsurance for an urgent care visit and an x-ray because this services was 
provided by an out-of-network provider. Based on the Plan contract, however, the cost-sharing for necessary 
urgently needed services furnished out-of-network is the same as for such services furnished in-network.  
Therefore, we decided that the Plan must reduce the cost-sharing to a $35 copayment for the urgent care visit 
and  X-ray.  
 
We also decided that the Plan does not have to waive the deductible for the walking boot. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 dollar deductible that applies to out-of-network services with 
limited exceptions. 
 
The item you asked the Plan to waive the deductible for was provided by an out-of-network deductible. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 dollar deductible that 
applies to out-of-network services with limited exceptions. This cost sharing is a contractual obligation that had 
not been met at the time a walking boot was received on November 22, 2021.Therefore, we decided that the 
Plan does not have to waive the deductible for the walking boot. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 7, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the laboratory services rendered on December 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner chair. 
 
You asked the Plan to pre-approve a recliner chair. You say that you need to put your legs up. The Plan denied 
your request. The Plan says this is not medical in nature. 
 
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 recliner chair.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Emergency Room visit (ER) on January 28, 
2022. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that you believe this should 
qualify as an inpatient admission and waive the copayment. The Plan denied your request. The Plan says the 
cost-sharing amount you are being charged is correct. 
 
 
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 $50 for 
each Medicare-covered emergency room visit. Emergency care refers to services that are: furnished by a 
provider qualified to furnish emergency services and needed to evaluate or stabilize an emergency medical 
condition.   
 
 
 You have been asked to pay a $50 copayment for emergency room visit. Emergency room visits fall within the 
Emergency care benefit category. You have a $50 copayment for each Medicare-covered emergency room 
visit. 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 Emergency Room visit (ER) on January 28, 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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the member is in need of acute rehab level of care 
after having a stroke. The Plan denied your request. The Plan says that the services the enrollee needs can be 
provided safely in other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for nausea, vomiting, 
atrial fibrillation and a stroke. The enrollees medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are needed for the enrollee 
to regain maximum functioning. The Plan denied your request. The Plan says that the enrollee does not meet 
criteria for these services. 
 
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. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where he is currently 
receiving care. All medically necessary care is being provided in the current acute care facility. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
 
 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) system (K0554) 
and sensor (K0553). 
 
You asked the Plan to pre-approve a CGM and related supplies. You say that the requested items are a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage of continuous glucose 
monitors and related supplies have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and 
related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) system (K0554) and sensor (K0553).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of the Minuteman G3-R minimally invasive surgery 
(MIS) fusion plate. 
 
You asked the Plan to pre-approve the Minuteman fusion plate. You say that this is a medically necessary 
treatment for the enrollee's condition. The Plan denied your request. The Plan says this is experimental at this 
time. 
 
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 Minuteman fusion plate. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this 93-year-old female was being treated for other intervertebral disc 
degeneration lumbosacral region. She presented noting the pain has decreased by 50%, with improvement in 
gardening. The most significant pain is in the low back and radiates to the right lower extremity.  
 
However, current evidence based medical guideline and peer reviewed literature do not fully support the interspinous fusion device procedure over the gold standard of lumbar fusion. There is a lack of large volume, 
long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical condition 
as discussed above. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of 
moderate spinal stenosis (including the planned level of implantation L4-L5.) FDA contraindications include 
spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical 
records. There is no discussion of spinal instability on flexion/extension films. There is no discussion of 
scoliosis of the lumbar spine.  
 
In addition, there are multiple alternate pain generators plausibly significantly contributing to the clinical 
condition that have not been fully documented as having been excluded and/or ruled out. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. Therefore, the requested spinal fusion with Minuteman procedure at L4-
5, in this case, is 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 the Minuteman fusion plate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve use of the Minuteman G3-R minimally invasive surgery (MIS) fusion plate.