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

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve the MyoPro Motion G orthosis. You say that this device is medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested device is considered 
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 the MyoPro Motion G orthosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the MyoPro is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 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 MyoPro Motion G orthosis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the MyoPro Motion G orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tetanus and diphtheria toxoids adsorbed (Td) (90714) 
and administration (90471) provided on May 17, 2022. 
 
You asked the Plan to pay for the vaccine. You say that you were never told that this shot would not be covered 
by insurance. You also say that you received a bill for $80. The Plan denied your request. The Plan says the 
vaccine in this case is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for the Tetanus and diphtheria toxoids adsorbed (Td) 
(90714) and administration (90471) provided on May 17, 2022.  
 
Benefits for the vaccine 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Group 3 Power Wheelchair. 
 
You asked the Plan to pre-approve the Group 3 Power Wheelchair. You say that you would like 
reconsideration because the requested wheelchair is medically necessary. The Plan denied your request. The 
Plan says the requested wheelchair exceeds the enrollee's needs. 
 The Plan follows Medicare rules. Medicare rules say that Group 3 Power Wheelchairs may be covered when 
specific criteria are met.  
 
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 Group 3 Power Wheelchair. Our 
reviewer says that the requested Group 3 Power Wheelchair (Q6 Edge 3mp-SS) is not medically necessary and 
appears to exceed the enrollee's medical needs. Our physician reviewer found without a clear objective treating 
physician physical exam the documentation does not support that this enrollee's mobility limitations cannot be 
helped by a properly fitted manual wheelchair. There is no evidence that the caregiver has limitations that 
would not allow propulsion in a manual wheelchair. At a T4 Spinal cord injury level the patient should have 
adequate upper extremity strength for manual wheelchair use and independence in transfers. Additionally the 
requested Q6 Edge 3MP-SS power wheelchair has deluxe features that exceed the patient's medical need such 
as  a USB charger, and drive wheel color accents. 
 
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 Group 3 Power Wheelchair have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Group 3 Power Wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care and wound debridement provided by 
an out-of-network provider on January 28, 2022. 
 
You asked the Plan to pay for the nursing facility care and wound debridement. You say that the medical notes 
and authorization letter are attached for review. You say that the claim should be reprocessed for payment. The 
Plan denied your request. The Plan says there was no prior authorization for out-of-network services and in-
network providers were available. 
  The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for the nursing facility care and wound debridement provided by an out-of-network provider on 
January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fitting for new contacts and contact lenses provided on 
April 15, 2022. 
 You asked the Plan to pay for a fitting for new contacts and contact lenses. You say that your understanding is 
that the Plan covers a yearly fitting and contacts with a deductible that is your responsibility. You also say that 
it has been one year and approximately four months since your prior. The Plan denied your request. The Plan 
says they will not provide the allowance if they have provider an allowance toward (or otherwise covered) 
lenses or frames within the same 24-month period. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan provide $150 allowance every 24 months that you can use to pay for eyewear. 
 
We looked at the file and the Plan's rules. The Plan rules say that they will not provide the allowance if they 
have provided an allowance toward (or otherwise covered) lenses or frames within the same 24-month period. 
The record shows that the previous eyewear was purchased on December 11, 2020. That is less than the 24-
month period. Based on this information, we decided that the Plan's rules for coverage of a fitting for new 
contacts and contact lenses have not been met. Therefore, we decided that the Plan does not have to pay for a 
fitting for new contacts and contact lenses provided on April 15, 2022.
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. 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 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 that there is no documentation provided indicating medical necessity for admission to 
a LTACH. You are receiving appropriate care at the present acute care hospital. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 14, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says this claim has not been filed 
timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until May 17, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on October 14, 2020.
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 enrollee would benefit from long-
term acute care due to medical complexity. The Plan denied your request. The Plan says the services needed 
could be provided in another setting. The enrollee's needs may be met at home with supervision and home 
health services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found 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 the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opsumit 10MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Opsumit 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 Opsumit 10MG tablet.  
 Benefits for the medication 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (81455) billed for date of service March 
10, 2022. You asked the Plan to pay for laboratory services. You say that this service was necessary and is supported in 
the records provided. The Plan denied your request. The Plan says there is insufficient information to support 
the medical necessity of this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. The rules say that while a physician order is not required to be signed, the 
physician must clearly document, in the medical record, his or her intent for the testing to be performed. Tests 
which are not ordered by the physician who is treating the enrollee are not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory services have been met. 
Specifically, the test requisition form is not signed. While this document is not required to be signed, there 
should be clear documentation in the record of an intent to perform this testing. No medical records or progress 
notes were provided to support the necessity of or intention for this test. Therefore, we decided that the Plan 
does not have to pay for laboratory testing (81455) billed for date of service March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing amounts for the intravitreal injection of a 
pharmacologic agent (67028), scanning computerized ophthalmic diagnostic imaging (92134), and Ziconotide 
injection (J2278) provided on April 19, 2022. 
 
You asked the Plan to waive the cost sharing amounts for the intravitreal injection of a pharmacologic agent, 
diagnostic imaging, and Ziconotide injection. You say that these services were medically necessary, and you 
believe they should be covered under your vision care benefit category. The Plan denied your request. The Plan 
says this claim processed 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 $45 
copay for specialist vision exams and a 20% coinsurance for each Medicare-covered Part B drug and 
chemotherapy service.  
 
You have been asked to pay a $45 copay for the intravitreal injection of a pharmacologic agent and diagnostic 
imaging combined, and a 20% coinsurance for the Ziconotide injection. The intravitreal injection of a 
pharmacologic agent and diagnostic imaging fall within the Vision care benefit category, and the Ziconotide 
injection falls within the Medicare Part B prescription drugs 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 cost sharing amounts for the intravitreal injection of a pharmacologic agent (67028), scanning 
computerized ophthalmic diagnostic imaging (92134), and Ziconotide injection (J2278) provided on April 19, 
2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (CPT code J0881). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred step therapy drug(s): 
Retacrit or Procrit. The Plan states there is no indication the preferred drug(s) would likely be: less effective, 
and/or cause adverse effects for the enrollee. 
 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 the medication. Our physician reviewer 
found the provided records do not indicate that the enrollee has tried and failed the plan's preferred step one 
alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse 
effect from the Plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. The 
requested service cannot be recommended. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Aranesp (CPT code J0881).
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 metabolic encephalopathy is an IRF compliant diagnosis and the enrollee has 
multiple comorbidities, but evaluating therapists specifically recommend less intense therapy in a skilled 
nursing facility. Thus, IRF criteria is not met and 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found this enrollee has severe chronic 
obstructive pulmonary disease (COPD) and was recently hospitalized with an exacerbation. The enrollee 
improved on bilevel positive airway pressure (BiPAP). Arterial blood gases (ABG) was consistent with acute-
on-chronic hypercarbic respiratory failure. The enrollee may benefit from BiPAP with average volume-assured 
pressure support (AVAPS) during sleep; this has not been tried and failed as an outpatient. Medicare does not cover a home ventilator when used as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient dermatology, acne surgery (10040) provided 
May 4, 2022. 
 
You asked the Plan to pay for the outpatient surgery. You say that you are asking for the claim to be reviewed 
because you had checked with the insurance company for the reconstructive surgery that is not covered. The 
Plan denied your request. The Plan says this procedure is considered cosmetic surgery ad is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient surgery have not been met. Therefore, we decided that the Plan does not have to pay 
for the outpatient dermatology, acne surgery (10040) provided May 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99024 billed for date of service April 5, 
2022. 
 
You asked the Plan to pay for procedure code 99024. The Plan denied your request. The Plan says procedure 
code 99024 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 99024 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99024 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99024 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99024 billed for date of service April 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on March 24, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the testing was billed 
incorrectly. 
 The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. 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 genetic testing 
services provided on March 24, 2022.