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

We decided that the Plan does not have to pre-approve a combination skin protection/positioning seat cushion. 
 
You asked the Plan to pre-approve combination skin protection/positioning seat cushion. You say that you sit 
in your wheelchair for 10 hours per day. The Plan denied your request. The Plan says the denial of 
authorization for this item is correct, because you do not have a qualifying diagnosis for a combination skin 
protection and positioning cushion. 
 
The Plan follows Medicare rules. Medicare rules state that a combination skin protection and positioning seat 
cushion is covered for a beneficiary who meets the criteria for both a skin protection seat cushion and a 
positioning seat cushion. 
 
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 combination skin protection/positioning 
seat cushion. Our reviewer says that you do not meet the Medicare criteria for this cushion. Our physician 
reviewer found for a combination skin protection and positioning cushion the patient must have a qualifying 
diagnosis. The records do not show that you have a qualifying diagnosis for this item. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of combination skin protection/positioning seat cushion have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a combination skin protection/positioning 
seat cushion.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient surgery rendered by the out-of-network (OON) provider from April 27, 2021, through April 28, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the outpatient surgery rendered by the out-of-network (OON) provider from April 27, 2021, through April 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter for the enrollee.
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation indicating problems completing MRADLs.
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 patient's 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 scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found there is no personal mobility deficit that impairs participation in MRADLs. The documentation does not support that the enrollee is unable to use a manual wheelchair, walker, or cane. The documentation does not support that the requested
power scooter will significantly improve the enrollee's ability to participate in MRADLs in the home. 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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
May 24, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the treatment was medically necessary, and 
the physician provided a statement of medical necessity and medical records to justify the reason for the 
enrollee's stay. The Plan denied your request. The Plan says enrollee's must receive their medical services from 
an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 

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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) 
provided on May 24, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99215, 96160) provided
April 22, 2021.
You asked the Plan to waive the copayment for the office visit. You say that the copayment should be waived.
The Plan denied your request. The Plan says the correct cost-sharing was applied.
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 50%
coinsurance for out-of-network primary care visits.
You have been asked to pay a 50% coinsurance for the office visit. The office visit falls within the out-ofnetwork
primary care visits 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 office
visit (99215, 96160) provided April 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve a complete upper denture. You say that the service at issue is necessary. The 
Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency 
limit of one every 5 years. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a complete upper denture have not been met. Specifically, the record shows that you had exceeded 
the frequency limit prior to this service on June 25, 2021. Therefore, we decided that the Plan does not have to 
pre-approve a complete upper denture (D5110).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic testing provided on September 
24, 2020. 
 
You asked the Plan to pay for the GeneSight Psychotropic testing. You say that the GeneSight Psychotropic 
testing provided on September 24, 2020 was medically necessary. The Plan denied your request. The Plan says 
the GeneSight Psychotropic testing provided on September 24, 2020 was 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 pay for the GeneSight Psychotropic testing. Our 
reviewer says that the GeneSight Psychotropic testing provided on September 24, 2020 was not medically 
necessary. Our physician reviewer found the enrollee is with a diagnosis of Bipolar disorder, unspecified. It is 
noted that Ativan (lorazepam) failed to work for this enrollee. The case file contains GeneSight Order Medical 
Necessity Documentation, and the results of the GeneSight Psychotropic Combinatorial Pharmacogenic test. 
Clinical records are lacking. The available documentation in the case file is insufficient to demonstrate that the 
GeneSight Psychotropic testing provided on September 24, 2020 was medically reasonable and necessary for 
the enrollee in this case. 
 
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 GeneSight Psychotropic testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the GeneSight Psychotropic testing provided on September 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan represented by code 70450 provided on June 8, 2021.
You asked the Plan to pay for code 70450. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
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 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 computed tomography (CT) scan represented by code 70450 provided on June 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the tissue exam (88305 XP) provided on February 19, 2021.
You asked the Plan to pay for the tissue exam. You say that the services were provided, and payment should be rendered. The Plan denied your request. The Plan says the claim is a duplicate of the same procedure code submitted by another provider.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the tissue exam have not been met. Therefore, we decided that the Plan does not have to pay for the tissue exam (88305 XP) provided on February 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power wheelchair with multiple power 
options and accessories. 
 
You asked the Plan to pre-approve a group 2 power wheelchair with multiple power options and accessories. 
You say that this equipment is medically necessary. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a group 2 power wheelchair with multiple power 
options is subject to the criteria listed 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 a group 2 power wheelchair with 
multiple power options and accessories. Our reviewer says that the requested items are not medically 
reasonable and necessary. Our physician reviewer found the documentation does not meet coverage criteria for 
a power tilt and power recline seating system. There is no evidence of intermittent catheterization, spasticity, or 
evidence of being high risk for a pressure ulcer or unable to perform a functional weight shift on the treating 
medical provider notes. Documentation from the provider does not discuss history of pressure ulcers past or 
current and the patient is able to sit to stand therefore should be able to functionally weight shift. As the power 
tilt and recline seating system coverage criteria have not been met, the request for the group 2 power 
wheelchair with multiple power options is not medically necessary. The requested accessories will not be 
covered as the base wheelchair is not covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 2 power wheelchair with multiple power options and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair 
with multiple power options and accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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. Our 
physician reviewer found the enrollee appears to be improving and more stable but still requires short-term 
additional acute care services to further stabilize which can be safely completed at the current acute care 
facility. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Transfer to a lower level of care may be considered when treatment has 
completed.

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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99233) provided April 20, 2021.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the claim did not include a valid diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 99233 is not supported in the medical record. Specifically, diagnosis code F05 requires
that the underlying or primary diagnosis be listed first. Based on this information, we decided that Medicare
rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not
have to pay for physician services (99233) provided April 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydrocodone/Acetaminophen tablets. 
 
You asked the Plan to pre-approve the Hydrocodone/Acetaminophen tablets. The Plan denied your request. 
The Plan says Hydrocodone/Acetaminophen is a self-administered drug and does not fall under Part B 
coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve 
Hydrocodone/Acetaminophen tablets.  
 
Benefits for the Hydrocodone/Acetaminophen tablets may be available under Medicare Part D. Contact the 
Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and the diagnostic tests provided on March 4,
2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit and diagnostic tests. You say that the services were medically
necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the services at issue were urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the office visit and the diagnostic tests provided on
March 4, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that
includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water
and/or phone bill payments (debit card), home assistance services (repairs).
You asked the Plan to pre-approve special supplemental benefits for the chronically ill that includes
transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or
phone bill payments (debit card), home assistance services (repairs). The Plan denied your request. The Plan
says the certification dated August 14, 2021 from your primary care physician documented that the enrollee has
Pre- Diabetes, none of the qualifying diagnoses, does not require intense care coordination, and has no high
risk for hospitalizations or high risk for adverse health outcomes.
The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you
must have one or more comorbid and medically complex chronic conditions that are life-threatening or
significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization
or other adverse health outcomes; and must require intensive care coordination.
We looked at the file and Medicare rules. The file shows that your medical conditions are not eligible medical
conditions for coverage under the Plan's benefit. Therefore, we decided that the Plan does not have to preapprove
special supplemental benefits for the chronically ill that includes transportation for non-medical needs,
an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home
assistance services (repairs).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC). 
 
You asked the Plan to pre-approve the requested PWC. You say that it is felt that this is necessary. The Plan 
denied your request. The Plan says this is not required for use in the home as you are able to complete 
MRADLs with the use of a walker or manual wheelchair. 
 
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 patient's 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 requested PWC. Our reviewer says 
that the documentation does not support that the criteria for the PWC are met in this case. Our physician 
reviewer found the enrollee is a female with recent findings of the ability to self-propel up to 200-300 feet in a 
manual wheelchair, as well as the ability to ambulate 100-150 feet with a walker. Distance needed to travel 
between rooms for MRADLs is 20-30 feet.

The documentation does not support that the patient has a mobility deficit that impairs MRADLs in the home 
and is not ameliorated by a walker or manual wheelchair. While the patient may have the cognitive capacity to 
safely use the requested wheelchair, the documentation does not support that this device is 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 requested PWC have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Group 2 power wheelchair (PWC).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services could be provided in another setting, such as an acute 
rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting or home care. 
 
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. Our 
physician reviewer found there is no documentation provided indicating medical necessity for the requested 
LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where he is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis. 

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 admission to a long-term acute care hospital (LTACH).