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

 
We decided that the Plan does not have to pre-approve the electronic connection between wheelchair controller 
and power option (E2310) and footplate pads (K0108). 
 
You asked the Plan to pre-approve the electronic connection between wheelchair controller and power option 
and footplate pads. You say that these items are medically necessary. The Plan denied your request. The Plan 
says these items cannot be covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules say that an electronic connection between the wheelchair controller and power 
option can be covered if there is a medical need for the enrollee to control two or more of motors from a single 
interface 
 
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 for the electronic connection. Our reviewer says that 
the requested electronic connection is not medically reasonable and necessary. Our physician reviewer found 
that in this case, the enrollee has adequate upper extremity strength and control to manage standard power 
switches for multiple drives. Therefore, there is no medical need to control he power options through a single 
interface. 
 
Furthermore, the footplate pads 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 the electronic connection between 
wheelchair controller and power option (E2310) and footplate pads (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement of your current power wheelchair and 
accessories (K0856, E2300, E2359, E1028x3, E1002, E2620, E2209, E1012, E0955, E0953, E2603). 
 
 You asked the Plan to pre-approve replacement of your current power wheelchair and accessories. You say that 
the enrollee's current heavy-duty chair is difficult to maneuver in his home due to its increased base size. The 
chair suspension and overall size of the chair cannot be modified to meet his current weight of 250 pounds. The 
Plan denied your request. The Plan says the enrollee currently has a power wheelchair that is less than 5 years 
old. Per Medicare rules, replacement due to wear is not covered during the reasonable useful lifetime of the 
equipment (less than 5 years). 
 
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 replacement of your current power 
wheelchair and accessories. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found per medical records, the current 
wheelchair, other than seating system is functional for the enrollee. Replacement of seating is less than 60% of 
replacement cost and consistent with Medicare rules on DME per chapter 15 Medicare Benefit manual. The 
power seat elevation is not medically necessary per Medicare NCD 280.1. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of replacement of your current power wheelchair and accessories have not been 
met. Therefore, we decided that the Plan does not have to pre-approve replacement of your current power 
wheelchair and accessories (K0856, E2300, E2359, E1028x3, E1002, E2620, E2209, E1012, E0955, E0953, 
E2603).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 billed for services provided on July 6, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports the claim. The Plan 
denied your request. The Plan says the service is included in payment for another service. 
 
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 99204 is office visit for the evaluation and management 
of a new patient. We find that CPT code 99204 was provided on the same day, by the same provider, as code 
64490. Code 64490 has a global surgery indicator of 000, which indicates an endoscopic or minor procedure.  Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99204 billed for services 
provided on July 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that the requested services are a medical necessity for you. 
The Plan denied your request. The Plan says the requested services are experimental/investigational. 
 
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 IGRT. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that IGRT is a technology for which need has not been established by published data or supported by 
consensus guidelines (many of which recommend against treatment with these devices in general). Daily IGRT 
or daily simulations (also requested in this case) would not be furnished in accordance with accepted standards 
of medical practice. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve IGRT.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 9, 2021 to 
November 17, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
principal diagnosis of A41.4 (sepsis due to anaerobes) and secondary diagnosis of R65.20 (severe sepsis 
without septic shock) were reported correctly. The Plan denied your request. The Plan says the principal 
diagnosis of A41.4 (sepsis due to anaerobes) and secondary diagnosis of R65.20 (severe sepsis without septic 
shock) are not supported in the medical record, resulting in a lower DRG being paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis of A41.4 (sepsis due to 
anaerobes) and secondary diagnosis of R65.20 (severe sepsis without septic shock). We asked our physician 
reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was 
correct in denying the request to pay for the inpatient hospital services at the DRG originally billed. Our 
reviewer says that the principal diagnosis of A41.4 (sepsis due to anaerobes) and secondary diagnosis of 
R65.20 (severe sepsis without septic shock) are not supported in the medical record. Our physician reviewer 
found the patient is a 96-year-old female who presented to the hospital with cough, fever, and shortness of 
breath and was diagnosed and treated for pneumonia. She was in no acute distress, was alert and oriented x 3, 
no hypoxia, leukocytosis, Creatinine of 1.31, normal platelets, normal liver function, and requiring fluids and 
antibiotics providing stable blood pressures. There was insufficient evidence of a life-threatening organ 
dysfunction directly related to a dysregulated host response as part of her infection and did not meet Sepsis 3 
criteria based on the provided documentation.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on November 9, 2021 to November 17, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) rendered from 
January 18, 2022, to February 28, 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 covered. 
 
The Plan must follow Medicare rules. The rules say that claims for E0675 will be denied as not reasonable and 
necessary. 
 
We looked at the file and Medicare rules. The services at issue are a PCD billed with code E0675. These 
services are denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have 
to pay for the pneumatic compression device (PCD) rendered from January 18, 2022, to February 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound on May 26, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for an ultrasound.  
 
You have been asked to pay a $25 copayment for an ultrasound. This item/service falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and 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 copayment for an ultrasound on May 26, 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. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically reasonable and necessary. The 
Plan denied your request. The Plan says rules for IRF care have 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 that the enrollee was admitted for stroke and was discharged home on October 26, 
2022. There is ongoing weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs. In this case, the enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. In conclusion, 
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. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on May 12, 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. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 represents TC only codes.  
 
We looked at the file and Medicare rules. Billed procedure code 99153 has a PC/TC indicator of 3 and has no 
separate PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation 
services rendered on May 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Covid-19 test kits on January 27, 2022. 
 
You asked the Plan to pay for Covid-19 test kits. You say that you would like to be reimbursed. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $9.99 
per test kit for Covid-19 test kits.  
 
You have been asked to pay $9.99 per test kit for Covid-19 test kits. 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 pay for 
Covid-19 test kits on January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says utilization of 
network providers and authorization for certain services are required. 
 
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 file shows that the enrollee was seen for a medication refill. The provider in this case is not a network 
provider with the Plan. The Plan had network providers available who could have provided the services at issue 
in this appeal. 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 office visit 
provided on May 5, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI. 
 
You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says advanced diagnostic 
imaging is generally not indicated following a clinically successful spinal fusion. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 pre-approve an MRI. Our reviewer says that medical 
necessity of the requested MRI of the cervical spine has not been established. Our physician reviewer found 
that there is no reason given by the requesting physician for an MRI other than a routine 6 month follow up 
after cervical spine fusion. There are no clinical symptoms reported, no neurological exam in the records and 
no plain film findings present to suggest fusion failure or delay. 
 
 
  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 MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an MRI.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enhertu. 
 
You asked the Plan to pre-approve Enhertu. 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 Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Enhertu. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found Enhertu is not Food and Drug 
Administration-approved for the treatment of HER2 positive extrahepatic cholangiocarcinoma or pancreatic 
adenocarcinoma. The use of Enhertu for the treatment of HER2 positive extrahepatic cholangiocarcinoma or 
pancreatic adenocarcinoma is not supported by one of the major drug compendia or by clinical research that 
appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Enhertu have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Enhertu.
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 heart failure and you do not think it would 
be safe to be discharged home without rehabilitation. You say you are very weak and need assistance getting 
out of bed. The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to 
a SNF. 
 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 you do not have documented skilled nursing or skilled therapy needs. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of your condition. Your 
care needs 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 27, 2021, to 
March 26, 2021. 
 
You asked the Plan to pay for home health services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
 
  We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the RAP for 
the period of care at issue was not submitted timely. Therefore, we decided that the Plan does not have to pay 
for home health services provided from February 27, 2021, to March 26, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that continued SNF care is medically necessary. 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 based on the medical records provided there is no documentation that further 
daily skilled services are required. There is no documentation that the enrollee requires these services on an 
inpatient basis, only in a skilled nursing facility setting. 
 
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 continued SNF care.