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

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve a MyoPro Motion G orthosis. You say that this is medically necessary for 
the enrollee's condition. 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 a 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 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 a MyoPro Motion G orthosis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro Motion G orthosis.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for your condition. The 
Plan denied your request. The Plan says that 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that you are a 66-year-old female with past medical history of multiple comorbidities hospitalized with 
19.5% total body surface area (TBSA) burns and multiple hospital complications and now with functional 
impairments. In this case, the clinical documentation shows that you have active comorbidities that require 
close medical monitoring of grafts and burn areas per plastic surgery and concern for contractures. Clinical 
documentation shows that you have complex functional impairments due to multiple areas of injury and that 
you would be expected to tolerate intense therapy. The criteria for coverage of IRF care have been 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery backup for a sleep apnea machine (A9270). 
 
You asked the Plan to pre-approve a battery backup. You say that you go through many power outages which 
affect the operation of your machine, which is vital for your breathing. The Plan denied your request. The Plan 
says the requested equipment is not of a medical nature; it is an alternative energy source. Medicare does not 
allow payment for electrical generators or alternate energy resources needed in the event of power outages even 
for enrollee's residing in a federally declared emergency area or major disaster area. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item 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 a battery backup for a sleep apnea machine (A9270).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management provided on July 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for pain management. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
  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 pain management provided on July 18, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right total knee arthroplasty. 
 
You asked the Plan to pre-approve a right total knee arthroplasty. You say that this procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says there is insufficient 
documentation that the enrollee has completed a course of conservative therapy as would be medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a right total knee arthroplasty. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee is a 73-year-old male being treated for right knee primary 
osteoarthritis. He presented with right knee pain that has been ongoing for 15 years. The pain is moderate and 
rated at 8/10. The symptoms are sharp and are getting worse. He has stiffness, limping, clicking, and giving 
way. The right knee exam reveals tenderness to palpation along the medial and lateral joint lines. The knee 
range of motion is from 5 to 100 degrees of flexion with pain at extremes of motion and crepitation throughout. 
The knee is stable to varus/valgus and anterior/posterior drawer testing.  
In this case, detailed documentation is not evident regarding a trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. There is no documentation of a failure of formal 
physical therapy. Moreover, he is noted to have had cortisone injections; however, no documentation of any 
other injections is documented to have been tried/failed. Additionally, the treatment plan on the exam indicated 
it was for a Makoplasty, which is not supported. Large volume long term studies evidencing ultimate outcomes 
of increased functionality and pain reduction (as compared to 'conventional' total knee arthroplasty are not 
evident. 
 
Overall, there is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the requested right total knee arthroplasty in this case, is 
not medically reasonable or necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a right total knee arthroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a right total knee arthroplasty.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency transportation (A0427) provided on 
December 14, 2021. 
 
You asked the Plan to pay for the emergency transportation. You say that the Plan must pay according to the 
Centers for Medicare & Medicaid Services (CMS) guidelines for a Medicare beneficiary. The Plan denied your 
request. The Plan says this claim was not billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that if the time of death pronouncement is after 
dispatch but before the beneficiary is loaded onboard the ambulance, the provider's/suppliers BLS base is paid, 
and the QL modifier must be used when submitting the claim. 
 
We looked at the file and Medicare rules. Specifically, because the enrollee passed away before transport was 
initiated, the BLS code plus modifier -QL is required. Based on this information, we decided that Medicare 
rules for coverage of the emergency transportation have not been met. Therefore, we decided that the Plan does 
not have to pay for the emergency transportation (A0427) provided on December 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the acute inpatient rehabilitation facility 
(IRF) admission provided from January 11, 2022, through January 20, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $300 copayment per admission, after the deductible is met, for each medically necessary inpatient 
stay.  
 
The enrollee has been asked to pay a $300 copayment for the inpatient hospital admission provided. This 
means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost 
sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for the acute inpatient rehabilitation 
facility (IRF) admission provided from January 11, 2022, through January 20, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 26445 billed for date of service May 27, 
2022. 
 
You asked the Plan to pay for procedure code 26445. The Plan denied your request. The Plan says payment for 
code 26445 is bundled into payment for code 26480.  
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 26445 
is a column II code to column I code 26480. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 26445 billed for date of service May 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral to a urogynecologist. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is medically necessary care available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral to a urogynecologist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a denosumab injection provided on July 5, 
2022. 
 
You asked the Plan to waive the coinsurance for a denosumab injection. You say that you would like to pay a 
lower amount, like a copayment instead of a coinsurance. 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 20% 
coinsurance for all drugs covered under Original Medicare.  
 
 
  You have been asked to pay $253.71 in coinsurance, which is 20% of the allowed amount for a denosumab 
injection ($1,268.53 x 20% = $253.71). This item/service falls within the drugs covered under Original 
Medicare 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 coinsurance for a denosumab injection 
provided on July 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injection services. 
 
You asked the Plan to pre-approve repeat epidural steroid injection services. You say that this is medically 
necessary for the condition. The Plan denied your request. The Plan says the criteria for repeat injections have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a repeat ESI will be considered medically 
reasonable and necessary when the medical record documents at least 50% of sustained improvement in pain 
relief and/or improvement in function measured from baseline for at least three months. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of repeat epidural steroid injection services have not been met. Specifically, the record indicates that 
the pain relief only lasted for two weeks, not the required three months. Therefore, we decided that the Plan 
does not have to pre-approve repeat epidural steroid injection services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
January 14, 2022, to February 3, 2022. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the NOA 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, this claim 
does not match the dates on the NOA. This claim is not payable as billed. Therefore, we decided that the Plan 
does not have to pay for the home health services provided to the enrollee from January 14, 2022, to February 
3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract surgery provided on August 02, 
2022. 
 
You asked the Plan to waive the copayment for cataract surgery. You say that you were informed you would 
not have to pay and the service would be covered by Medicare completely. 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 $300 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $300 copayment for cataract surgery. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 cataract surgery provided on 
August 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77003 and 95971 billed for date of service 
July 11, 2022. 
 
You asked the Plan to pay for procedure code 77003 and 95971. You say that this should be paid for. The Plan 
denied your request. The Plan says payment for code 77003 and 95971 is bundled into payment for code 
63650. 
 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 codes 
77003 and 95971 are column II codes to column I code 63650. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 77003 and 95971 billed for 
date of service July 11, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health skilled nursing care services provided from April 12, 
2022, to May 11, 2022. 
 
You asked the Plan to pay for the home health skilled nursing care services. The Plan denied your request. The 
Plan says that there are no medical records or progress notes that address the actual appeal dates. The Plan also 
says that medical necessity cannot be decided on the wound care and services received on the given dates 
without these documents. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that medical records for the dates of service at appeal were not provided 
with this case. The record does not show that the Plan made any attempts to obtain this documentation. Without 
this information we cannot determine that the Plan's coverage rules support the denial of payment in this case, 
or that the services provided were not medically necessary. Consequently, the Plan has not substantiated their 
denial of payment in this case. Therefore, we decided that the Plan has to pay for the home health skilled 
nursing care services provided from April 12, 2022, to May 11, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
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. The Plan denied your request. The Plan says the enrollee does not 
meet the conditions for a stay in an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that 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. Our physician reviewer also found that there is not a reasonable expectation that this enrollee 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.