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

 
We decided that the Plan does not have to pre-approve the lightweight wheelchair (K0003). 
 
You asked the Plan to pre-approve the wheelchair. You say that you have a bad back and cannot lift a 30-pound 
wheelchair. Both of your caregivers hurt their back lifting your regular wheelchair. The Plan denied your 
request. The Plan says The request for the lightweight manual wheelchair does not meet medical necessity 
criteria 
 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 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 is independent with mobility in the home and performing his activities of daily 
living with the use of a walker. There is no indication that the enrollee cannot propel a standard manual 
wheelchair. The ability to lift a wheelchair is not a criterion for the necessity of a lightweight manual 
wheelchair. Therefore, the lightweight manual wheelchair is 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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the lightweight wheelchair (K0003).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the nursing facility care provided on March 16, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the service was provided at the enrollee's 
residence. The Plan denied your request. The Plan says that the rendering provider is an OON provider and 
there was no approved authorization for the services rendered. 
 
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 claim information submitted lists a referring physician. The Plan did not 
submit documentation supporting that the referring physician is also out-of-network. Therefore, we decided 
that the Plan has to pay for the nursing facility care provided on March 16, 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: 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 appealing, on behalf of the enrollee, the pre-
service denial of inpatient rehabilitation facility admission. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare criteria for admission to an inpatient rehabilitation facility. 
 
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 was admitted for cardiac arrest, myocardial infarction, and 
pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the 
enrollee has a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on January 31, 2022. 
 
You asked the Plan to pay for psychotherapy services. The Plan denied your request. The Plan says the member 
was under hospice on this date of service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for psychotherapy services provided on January 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of spinal canal and 
contents, cervical (72141), MRI of brain (70553), MRI of spinal canal and contents, lumbar (72148), and 
magnetic resonance angiography (MRA), head (70544) to be provided out-of-network. 
 
You asked the Plan to pre-approve the services provided out-of-network. You say that the requested provider is 
the only with an MRI machine with a 0.7 tesla or lower. You say that you had a metal implant placed in 2015. 
You also say that you had an MRI with an out of network provider previously and there was no problem. The 
Plan denied your request. The Plan says the requested services can be provided in network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 services provided out-of-network. 
Our reviewer says that the requested services to be performed out-of-network is not medically necessary. Our 
physician reviewer found the documentation does not clearly support that the in-network providers are 
adequate to meet your needs with 0.7 Tesla MRI. The documentation indicates that one of the hospitals may be 
able to accept you, but they would need to evaluate you first. The reviewer also found that the provided 
documentation does not clearly indicate that the in-network providers have adequate equipment to meet the 
enrollee's needs. Therefore, the reviewer found that the request to receive these services out-of-network 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 services provided out-of-network have not been met. Specifically, the file 
shows that there may be one in-network facility that can provide the requested services with an MRI machine 
with 0.7T or lower. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance 
imaging (MRI) of spinal canal and contents, cervical (72141), MRI of brain (70553), MRI of spinal canal and 
contents, lumbar (72148), and magnetic resonance angiography (MRA), head (70544) to be provided out-of-
network.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for catheters provided from December 15, 
2021, to June 23, 2022. 
 
You asked the Plan to waive the coinsurance for catheters. You say that you did not realize these items would 
be so costly and would have had your provider help you make a different treatment plan had you known. The 
Plan denied your request. The Plan says the coinsurance applied was 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 a 20% 
coinsurance for prosthetic devices and related supplies ($1144.80 x 20% = $228.96) + ($1,081.20 x 20% = 
$216.24) + ($3,607.20 x 20% = $721.44) + ($3,607.20 x 20% = $721.44) = $1888.08. 
 
You have been asked to pay a $1888.08 coinsurance for catheters. Catheters fall within the Prosthetic Devices 
and Related Supplies 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 for catheters 
provided from December 15, 2021, to June 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81161 billed for date of service November 5, 
2021. 
 
You asked the Plan to pay for procedure code 81161. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 81161 is bundled into 
payment for code 81413. 
 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 81161 
is a column II code to column I code 81413. 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 81161 billed for date of service November 5, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve Gel-One. You say that this is medically necessary. The Plan denied your 
request. The Plan says that you do not have any stated contraindications to the preferred products. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Gel-One. Our reviewer says that Gel-
One is not medically reasonable and necessary. There is no indication that you have tried and failed Orthovisc, 
Synvisc or Synvisc-One. There is no indication that the Plan's required drugs would likely be less effective 
and/or likely have adverse effects for you. Our physician reviewer found that your condition does not meet step 
therapy criteria for Gel-One. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that additional physical therapy is medically 
necessary. The Plan denied your request. The Plan says these services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the enrollee has been instructed in and compliant with a home 
exercise program. It is unclear why the continued services of a skilled physical therapist are required. 
Therefore, the additional 12 visits of therapy 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 therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 12 physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 14-day reader. 
 
You asked the Plan to pre-approve a FreeStyle Libre 14-day reader. 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. 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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a FreeStyle Libre 14-day reader have not been met. Therefore, we decided that the Plan does not have to pre-
approve a FreeStyle Libre 14-day reader.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet injections (64493, 64494, 64495). 
 
You asked the Plan to pre-approve facet injections. You say that you have rheumatoid arthritis and have been 
dealing with it since you were 8 years old. The swelling has gone down but you are still dealing with a lot of 
pain except for your lower back which you need the injections for. The Plan denied your request. The Plan says 
you have chronic pain syndrome and rheumatoid arthritis. This does not meet criteria for injections. 
 
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 facet injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review of systems is positive for weakness, and tingling. The treatment plan includes 
opioids. Your diagnoses include lumbar radiculopathy, and chronic pain syndrome. The documentation does 
not reveal a hand on detailed physical examination supporting the need for this injection and supporting that 
your current pain condition in the low back is due to facet pathology. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet injections (64493, 64494, 64495).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 2, 2022, billed with 
codes 81162, 81201, 81292 81295, 81298, 81314 81317, 81321, 81334 81351, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the claim has not been billed as required by 
Medicare billing regulations. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 2, 2022, billed with codes 81162, 81201, 81292 81295, 81298, 81314 81317, 81321, 81334 81351, and 
81479.
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 requesting admission to the IRF versus 
admission to a skilled nursing facility as you have been receiving excellent care at the hospital. The Plan denied 
your request. The Plan says the service is not reasonable and necessary and you do not meet Medicare criteria 
for admission IRF level of care. 
 
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 were admitted for peripheral vascular disease and a below the knee 
amputation. Medical problems are stable. There are no complex nursing or rehabilitation needs. While you 
have a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of intra-socket biological dressing (D7922) 
and a therapeutic parenteral drug (D9610). 
 
You asked the Plan to pre-approve placement of intra-socket biological dressing and a therapeutic parenteral 
drug. You say that the services are necessary. The Plan denied your request. The Plan says the services are not 
a covered 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 pre-approve 
placement of intra-socket biological dressing (D7922) and a therapeutic parenteral drug (D9610).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on December 27, 2021. 
 
You asked the Plan to pay for acupuncture. The Plan denied your request. The Plan says a licensed 
acupuncturist is a non-covered provider type and the provider is not supervised by any physician, physician 
assistant, nurse practitioner or a clinical nurse specialist.  
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, a licensed acupuncturist is a non-covered provider 
type and the provider is not supervised by any physician, physician assistant, nurse practitioner or a clinical 
nurse specialist. Therefore, we decided that the Plan does not have to pay for acupuncture services provided on 
December 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that the compression stockings give you 
relief. The Plan denied your request. The Plan says that this is not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.