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

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair (K0003). 
 
You asked the Plan to pre-approve a wheelchair. You say that the enrollee has significant limitations with 
mobility that interfere with mobility related activities of daily living. The Plan denied your request. The Plan 
says the enrollee does not meet medical necessity guidelines. 
 
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 a wheelchair. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has undergone revision surgery given a peri-prosthetic hip fracture. The enrollee 
requires assistance with mobility and daily activities and would benefit from a manual wheelchair for mobility 
given that he is not functionally ambulatory at this time with a cane or walker. The letter of appeal indicates 
that the patient can use a lightweight manual wheelchair, but there continues to be a lack of information 
regarding why the enrollee cannot use a standard manual wheelchair to meet their mobility needs. Therefore, 
the lightweight manual wheelchair is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lightweight wheelchair (K0003).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an esophagogastroduodenoscopy billed with code 43270 on 
May 11, 2022. 
 
You asked the Plan to pay for an esophagogastroduodenoscopy billed with code 43270. You say that this 
should be covered. The Plan denied your request. The Plan says this is not documented. 
 
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 43270 is esophagogastroduodenoscopy, flexible, 
transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire 
passage, when performed). 
 
We asked our coder 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 an esophagogastroduodenoscopy billed with code 43270. 
Our reviewer says that this code is not supported. Our reviewer found the submitted records do not document 
the ablation of tumors or polyps. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an esophagogastroduodenoscopy billed with code 43270 have not been met. 
Therefore, we decided that the Plan does not have to pay for an esophagogastroduodenoscopy billed with code 
43270 on May 11, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the records support the need for SNF care. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for skilled nursing care and does not 
require daily physical or occupational therapy. 
 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 the enrollee does not have documented skilled nursing needs.  The enrollee does not 
have documented skilled therapy needs. The enrollee is functioning at her baseline. Daily skilled services are 
not required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees care needs can, as a practical matter, 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 skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on Medicare 
guidelines the inpatient rehabilitation facility services you are requesting do not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for kyphoplasty for an L2 fracture after a fall. Medical 
problems are stable.  There are no complex nursing or rehabilitation needs. While the enrollee has a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for training for self-care or home management provided on 
 July 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for training for self-care or home management. You are appealing with supporting 
records. The Plan denied your request. The Plan says the enrollee must receive care from a 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 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 training for self-care or home management 
provided on July 7, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee medical management and rehab needs 
require an IRF stay and close Physician supervision. You say that the enrollee needs this care to be able to 
return home at their maximum level of functioning, and with a decreased risk for readmission. The Plan denied 
your request. The Plan says an IRF admission is not medically necessary, and the enrollee can receive the care 
they need in another setting. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic test provided on May 
5, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic test. You say that you are disputing the 
cost share for the aforementioned service. 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 $95 
copayment for Medicare-covered diagnostic procedure and test.  
 
You have been asked to pay $95 copayment for outpatient diagnostic test. This item/service falls within the 
Medicare-covered diagnostic procedure and test 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 outpatient diagnostic test provided on May 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services. 
 
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 this was not reported properly. 
 
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 72128 is Computed tomography, thoracic spine; without 
contrast material. 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that on 3/12/22, computed 
tomography of the cervical, thoracic and lumbar spine were done. Only one unit of CT thoracic spine was done. 
There are separate codes which should have been used for the CT of the cervical and thoracic spine. 
 
We looked at this coder's review, the file, and Medicare rules. 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
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee no longer requires daily skilled nursing/rehabilitation services for treatment 
of their illness. 
 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 the enrollee no longer qualifies for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollees feeding tube is established. The enrollee does not have 
documented skilled therapy needs. The enrollee has reached a new, lower, plateau in function. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs, custodial and intermittent, can, as a practical matter, 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 continued skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet criteria for SNF care. 
 
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 had a stroke and have right hemiplegia.  You are currently in an inpatient rehab 
facility.  You are receiving oral medications and have stable vital signs. You are dependent with functional 
mobility and require a mechanical lift for transfers. You require varying levels of assistance with activities of 
daily living. You do not have skilled nursing needs, but you do have skilled therapy needs. However, you do 
not require skilled therapy on a daily basis in an inpatient skilled nursing 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 skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that this service is medically necessary 
as the enrollee has a 20 pack-year smoking history and a history of multiple cancers. The Plan denied your 
request. The Plan says the criteria for coverage of an LDCT scan are not met in this case. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
 We reviewed the file and the Medicare rules. We find that the enrollee is not within the required age range of 
50-77 years old. Therefore, we decided that the Plan does not have to pre-approve a low dose computed 
tomography (LDCT) scan for lung cancer screening.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the record indicates that the enrollee has chronic low back pain and lumbar spinal stenosis 
with neurogenic claudication. The record indicates that the enrollee has had imaging studies that have 
multilevel degenerative changes and central and foraminal canal stenoses ranging from mild to severe. The 
record indicates that the enrollee has a problem list including morbid obesity but no recent body mass index is 
noted. The record does not document that the enrollee is not indicated for operative intervention at no more 
than two levels. The elements of the coverage criteria are not satisfied. 
 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a preparatory prosthesis to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from network providers. 
 
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 
a preparatory prosthesis to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 49905 and 43235-59 billed for date of 
service April 18, 2022. 
 
You asked the Plan to pay for procedure codes 49905 and 43235-59. You say that these services were reported 
correctly. The Plan denied your request. The Plan says these services are not supported 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. 
 
We asked our coder 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 procedure codes 49905 and 43235-59. Our reviewer says that 
these services are not supported in the medical record. Our reviewer found that the operative report does not 
include enough documentation to confirm that code 49905 has been performed as defined by the CPT Code 
Manual. In addition, the record shows that a gastric surgical laproscopy was performed which would include a 
diagnostic procedure. A diagnostic endoscopy may be reported separately when performed at the same surgical 
session as an open procedure. In this case, a surgical laparoscopic procedure was performed. Therefore, modifier -59 for code 43235-59 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 49905 and 43235-59 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 49905 and 43235-59 billed for date of service April 18, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the periodic evaluation (D0120), the cleaning (D1110), 
and the bitewing x-rays (D0274) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that the out-of-network provider is the only 
dentist who can successfully perform the services without causing you anxiety or discomfort. The Plan denied 
your request. The Plan says dental services from an out-of-network provider are not covered by your 
supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve the periodic 
evaluation (D0120), the cleaning (D1110), and the bitewing x-rays (D0274) to be provided by an out-of-
network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health therapy services (reported with codes 97535, 
97110 and 97530) provided from February 2, 2021, to February 23, 2021. 
 
You asked the Plan to pay for therapy services. You say that these were medically necessary services which 
were provided in good faith and should be paid. The Plan denied your request. The Plan says these services 
were provided as part of a home health care plan and submitted on a home health bill type. There are more 
appropriate codes to report these services. 
 
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 codes 97535, 97110 and 97530 are not supported in the medical record. Specifically, the type 
of bill submitted was a home health services bill (code 343). The medical records indicate that these therapy 
services were provided as part of a home health plan of care. However, these services were not reported using 
the appropriate home health therapies CPT code(s). Based on this information, we decided that Medicare rules 
for coverage of therapy services have not been met. Therefore, we decided that the Plan does not have to pay for home health therapy services (reported with codes 97535, 97110 and 97530) provided from February 2, 
2021, to February 23, 2021.