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

We decided that the Plan does not have to pre-approve an upper limb myoelectric prosthesis with 
independently articulating digits for the enrollee. 
 
You asked the Plan to pre-approve the prosthesis. You say that this is medically necessary. The Plan denied 
your request. The Plan says this request exceeds the enrollee's medical need. 
 
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 prosthesis is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records for this case contain conflicting documentation with regard to the type of 
prosthesis indicated for the enrollee and desired by the enrollee. One note from 4/16/21 states that the enrollee 
has been using a body-powered prosthesis for years and he is requesting replacement of the body-powered 
prosthesis as opposed to a myoelectric prosthesis. Another note from 05/18/2021 states a body powered 
prosthesis is contra-indicated. There is no explanation from the vendor or the prescribing provider to clarify 
these disparate assessments or to explain what changed in the weeks between these statements to necessitate 
the myoelectric prosthesis. 
 
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 an upper limb myoelectric prosthesis with independently articulating digits for the 
enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three (3) office consultations (CPT code 99214), to be 
provided by an out-of-network providers. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the enrollee is non-compliant with 
the in-network provider's care. The Plan denied your request. The Plan says the services can be provided by an 
in-network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
three (3) office consultations (CPT code 99214), to be provided by an out-of-network providers.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right shoulder arthroplasty (CPT code 23472) and 
inpatient hospital admission to be provided by an out-of-network provider.  
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says the service is available by a provider in the enrollee's network.  
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested 
provider in this case is not a network provider with the Plan. The Plan has network providers available who can 
provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-
approve these items/services. Therefore, we decided that the Plan does not have to pre-approve right shoulder 
arthroplasty (CPT code 23472) and inpatient hospital admission to be provided by an out-of-network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a visit provided by a psychology doctoral degree (Ph. D.) on 
April 12, 2021. 
 
You asked the Plan to pay for psychology doctoral visit. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
there is no documentation of consultation with the enrollee's attending or primary care physician. 
 
The Plan must follow Medicare rules. Medicare rules say that for services of a psychology doctoral practitioner 
to be covered, the provider must attempt to consult the enrollee's attending or primary care physician.  
 
We looked at the file and Medicare rules. The record does not show that this provider attempted to consult the 
enrollee's attending or primary care physician prior to rendering service. Based on this information, we decided 
that Medicare rules for coverage of psychology doctoral visit have not been met. Therefore, we decided that the 
Plan does not have to pay for a visit provided by a psychology doctoral degree (Ph. D.) on April 12, 2021.
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 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. 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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While the documentation does support a need for physical 
and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 
program. There is not a reasonable expectation that you 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on May 10, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this 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 non-covered. 
 
We looked at the file and Medicare rules. In this case, more than 6 targets were tested. Per LCD L37713, 
panels of more than 6 pathogens are not covered. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the 
lab services provided on May 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walker purchased on July 6, 2021. 
 
You asked the Plan to pay for a walker. You say that you would like this equipment covered for medical 
necessity. The Plan denied your request. The Plan says the provider is not a contracted durable medical 
equipment supplier with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a walker purchased on July 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an air pressure mattress (E0277). 
 
You asked the Plan to pre-approve the mattress. You say that you are unable to use a cover pad, and you need 
an air mattress. The Plan denied your request. The Plan says this 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 mattress. Our reviewer says that the 
requested mattress is not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the medical records provided, there is no documentation of either multiple stage II pressure 
ulcers located on the trunk or pelvis, which have been treated in a comprehensive program, large or multiple 
stage III or IV pressure ulcer(s) on the trunk or pelvis or a myocutaneous flap or skin graft for a pressure ulcer 
on the trunk or pelvis within the past 60 days. 
 
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 mattress have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an air pressure mattress (E0277).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on May 18, 2021. 
 
You asked the Plan to pay for physical therapy services. You say that plans are required to pay non-contracted 
providers at the preferred provider rate when services are not available in the service area. You say that the in-
network benefits should be honored, and the claim processed for payment. The Plan denied your request. The 
Plan says the code is not appropriate for the service billed. 
  
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on May 18, 2021.
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 the stay is medically necessary. The Plan denied your request. The Plan says the enrollee's records do not show they do not require skilled nursing services or skilled rehabilitation services on a daily basis, and which can only be provided on an inpatient basis in a SNF. The Plan states the enrollee's rehabilitation and medical needs can be met with part-time skilled services in a lower level of care, such as home with supervision and home health services. The Plan states home health services will need to be approved by the enrollee's health plan.
The Plan states the enrollee's rehabilitation needs can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with your doctor.
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 daily skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs are custodial and, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (CPT 70450) provided to the enrollee on 
June 26, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the appropriate was not billed in this case. 
 
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, the CPT Code Manual definition of code 70450 is "Computed tomography, head or brain; without 
contrast material." 
 
We find that CPT code 70450 is not supported in the medical record. Specifically, the appropriate modifier was 
not billed in this case to allow this code to be billed separately from CPT 70496. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for imaging services (CPT 70450) provided to the enrollee on June 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve enteral formula. 
 
You asked the Plan to pre-approve enteral formula. 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 follows Medicare rules. Medicare rules say that enteral formulas consisting of semi-synthetic intact 
protein/protein isolates (B4150 or B4152) are appropriate for the majority of beneficiaries requiring enteral 
nutrition. 
 
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 enteral formula. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found enteral nutrition for beneficiaries with a 
functioning gastrointestinal tract whose need for enteral nutrition is not due to reasons related to the non-
function or disease of the structures that normally permit food to reach the small bowel will be denied as non-
covered, no benefit. Orally administered enteral nutrition products, related supplies and equipment will be 
denied non-covered, no benefit. The review indicates that you do not meet the coverage criteria detailed in the 
LCD. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of enteral formula have not been met. Therefore, we decided that the Plan does not 
have to pre-approve enteral formula.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 25, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that it is the responsibility of the referring 
physician to obtain prior authorization. The Plan denied your request. The Plan says the services were not 
urgent, emergent, or approved in advance. 
 
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 provider in this case is not a network provider with the Plan. The referring provider is also not a network 
provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would 
require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on April 25, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
February 11, 2019, to February 26, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that The manual provides a chart which indicates that 
the 14-day assessment must have an ARD set on day 13 or 14 of the SNF stay and that this assessment sets the 
payment rate for days 15 through 30 of the stay. It is also noted that the 14-day assessment must be completed 
within 14 days of the ARD date used.  
 
We looked at the file and Medicare rules. In this case, as the 14-day assessment was not completed within 14 
days of the ARD date, it is not valid/not in compliance. Therefore, day 15 of the stay is correctly paid at the 
AAA default rate. Based on this information, we decided that Medicare rules for coverage of the services have 
not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) 
services provided from February 11, 2019, to February 26, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fifteen skilled nursing home health visits for the 
enrollee. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says teaching and education should have occurred in the previous approved visits. 
 
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 visits. Our reviewer says that the 
requested visits are not medically reasonable or necessary. Our physician reviewer found there are no 
documented skilled nursing needs. As such, the request home health skilled nursing services 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 the visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve fifteen skilled nursing home health visits for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF) 
for the enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says wound care could be performed with home health care in the assisted living 
facility. 
 
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 the admission. Our reviewer says that 
the requested continuation of services is not medically reasonable or necessary. Our physician reviewer found 
the enrollee no longer qualifies for SNF coverage. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued admission to a skilled nursing facility (SNF) for the enrollee.
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 the stay is medically necessary. The Plan denied 
your request. The Plan says you are not currently stable for discharge. The Plan states you would not currently 
be stable for SNF discharge. 
 
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 daily 
skilled services are not necessary. Our physician reviewer found there is no documentation that you require 
skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are 
not required to safely and effectively provide medically necessary and reasonable treatment. You do require 
skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required 
to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not 
required. You do not require the services on an inpatient basis, only in a skilled nursing facility setting. 
Services in a long-term care facility on a part time basis appear appropriate in this case when medically stable 
for discharge. 
 
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.