Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy. You say that the enrollee has chronic conditions, and they 
are unable to manage their symptoms without intermittent visits. You say that the enrollee experiences a 
notable decline in function whenever therapy was required to stop due to lack of insurance authorization. The 
Plan denied your request. The Plan says an additional 4 physical therapy visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the enrollee does not require the unique skills of a professional 
therapist to safely and effectively provide treatment. The services can be safely and effectively performed only 
by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance 
program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, 
design, or deliver a program to maintain the enrollee's current condition to prevent or slow further 
deterioration. The enrollee can transition to an independent home exercise program and does not require the 
ongoing skills of a professional therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 4 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit (99213) billed for date of 
service April 1, 2022. 
 
You asked the Plan to pay for an office or other outpatient visit. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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. 
 
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 an office or other outpatient visit have 
been met. Specifically, no medical records for the date of service at issue have been provided. The record 
shows that the Plan has made attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for an office or other outpatient visit (99213) billed for date of 
service April 1, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 12 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
   
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee appears to continue to have functional deficits with daily 
activities and mobility. However, there is insufficient documentation indicating that the enrollee is making 
progress with therapy, specifically with regards to motor strength, range of motion and function. It is not clear 
if the enrollee continues to require the skilled services of a physical therapist versus assistance with daily 
activities and mobility that can be provided by someone other than a skilled therapist. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional 12 physical therapy (PT) visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine culture (87086) provided on June 29, 2022. 
 
You asked the Plan to pay for the urine culture. You say that this test was medically necessary and was ordered 
by the enrollee's physician. The Plan denied your request. The Plan says the diagnosis code billed on this claim 
is inappropriate for this service and does not indicate that this service was medically necessary. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The diagnosis submitted on this claim was personal history of urinary (tract) infections (Z87.440). No other 
diagnosis was submitted. This diagnosis does not suggest that this test was provided to evaluate/investigate any 
relevant symptoms. This means that the test at issue in this appeal, the urine culture, was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that 
the Plan does not have to pay for the urine culture (87086) provided on June 29, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the ankle foot orthosis (L1971-LT) provided on July 7, 2022. 
 
You asked the Plan to pay for the ankle foot orthosis. You say that the claim should be paid. The Plan denied 
your request. The Plan says that the services are not supported by the records. 
 
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 L1971 is ankle foot orthosis. 
 
We find that CPT code L1971 is ankle foot orthosis is supported in the medical record. Review of the file 
shows that the left ankle foot orthosis is supported by the records provided. Based on this information, we 
decided that Medicare rules for coverage of the ankle foot orthosis have been met. Therefore, we decided that 
the Plan has to pay for the ankle foot orthosis (L1971-LT) provided on July 7, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87900 billed for date of service March 8, 
2022. 
 
You asked the Plan to pay for procedure code 87900. You say that the service at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the available medical records do not support the 
service 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, the CPT Code Manual definition of code 87900 is: Infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics. 
 
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 code 87900. Our reviewer says that the code at 
issue does not meet criteria for payment. Our reviewer found that the provided laboratory report does not 
include that quantitative infectious agent drug susceptibility was completed; therefore, this procedure 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 code 87900 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87900 billed for date of service March 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch ultra-test strips. 
 
You asked the Plan to pre-approve OneTouch ultra-test strips. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this is not the Plan's preferred item. 
 
The Plan follows Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment 
(DME) to only those preferred brands and manufacturers. 
 
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 OneTouch ultra-test strips. Our 
reviewer says that the member does not need this item. Our physician reviewer found no reason is given as to 
why the member needs the non-preferred brand and why their needs could not be met with the preferred brand 
strips/meter. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OneTouch ultra-test strips have not been met. Therefore, we decided that the 
Plan does not have to pre-approve OneTouch ultra-test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested power seat elevation feature (E2300), 
expandable controller (E2377), expandable controller harness (E2313), electronic connection (E2311) to 
control power tilt, recline and power elevating leg rests through the joystick. 
 
You asked the Plan to pre-approve the requested power seat elevation feature (E2300), expandable controller 
(E2377), expandable controller harness (E2313), electronic connection (E2311) to control power tilt, recline 
and power elevating leg rests through the joystick. You say that the requested power seat elevation feature 
(E2300), expandable controller (E2377), expandable controller harness (E2313), electronic connection (E2311) 
to control power tilt, recline and power elevating leg rests through the joystick are medically necessary. The 
Plan denied your request. The Plan says the requested power seat elevation feature (E2300), expandable 
controller (E2377), expandable controller harness (E2313), electronic connection (E2311) to control power tilt, 
recline and power elevating leg rests through the joystick are 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 pre-approve the requested power seat elevation 
feature (E2300), expandable controller (E2377), expandable controller harness (E2313), electronic connection 
(E2311) to control power tilt, recline and power elevating leg rests through the joystick. Our reviewer says that 
the requested power seat elevation feature (E2300), expandable controller (E2377), expandable controller 
harness (E2313), electronic connection (E2311) to control power tilt, recline and power elevating leg rests 
through the joystick are not medically necessary. Our physician reviewer found the enrollee has very limited 
strength in right arm due to spinal cord injury. He does have 3+/5 strength in left upper extremity and will have left sided controls. Per A52504 and Medicare rules on medical necessity, the enrollee has sufficient strength to 
manage standard power switches. 
 
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 power seat elevation feature (E2300), expandable controller 
(E2377), expandable controller harness (E2313), electronic connection (E2311) to control power tilt, recline 
and power elevating leg rests through the joystick have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the requested power seat elevation feature (E2300), expandable controller (E2377), 
expandable controller harness (E2313), electronic connection (E2311) to control power tilt, recline and power 
elevating leg rests through the joystick.
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 the enrollee is moderately deconditioned after by-pass surgery. He has experienced successful by-pass and is expected to continue to rapidly improve with repetitive exercise. He does not require 
intensive rehabilitation. He does not require frequent physiatry oversight. He is a little less functional than most 
by-pass patients but his endurance is similar and recovery from by-pass surgery generally occurs at home with 
repetitive exercise. Admission to an IRF 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ventolin. 
 
You asked the Plan to pre-approve Ventolin. You say that the records provided support that the requested drug 
is medically necessary. The Plan denied your request. The Plan says he requested drug falls under Part D. The 
Plan says that they do not administer Part D benefits for the enrollee. 
 
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 Ventolin.  
 
Benefits for Ventolin 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 procedure codes 88341, 88342, and 88360 billed for date of 
service March 21, 2022. 
 You asked the Plan to pay for procedure codes 88341, 88342, and 88360. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says this code is included in the facility payment and is 
not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88341, 88342, and 
88360. This means there is both a professional and technical component for the CPT codes. In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT codes 88341, 88342, 
and 88360. Based on this information, we decided that Medicare rules for coverage of procedure code 88341, 
88342, and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 88341, 88342, and 88360 billed for date of service March 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the elbow orthosis provided on July 28, 2022. 
 
You asked the Plan to pay for the elbow orthosis. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the documentation submitted did not sufficiently support the billed supply 
code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 
 
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Review of the file shows that the documentation submitted did not sufficiently support the billed 
supply code. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the elbow orthosis provided on 
July 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myrbetriq. 
 
You asked the Plan to pre-approve Myrbetriq. You say that the medication is necessary. The Plan denied your 
request. The Plan says your plan does not have a Medicare Part D benefit, or a separate pharmacy benefit 
managed by the plan, therefore self-administered drugs do not meet the criteria for 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 Myrbetriq.  
 
Benefits for Myrbetriq 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 an addition, endoskeletal system, below knee, flexible 
protective outer surface covering system (L5962), an addition to lower limb prosthesis, multiaxial ankle with 
swing phase active dorsiflexion feature (L5968) and an all-lower extremity prosthesis, flex-walk system 
(L5981). 
 
You asked the Plan to pre-approve prosthetic leg replacement. You say that the enrollee needs the requested 
prosthetics due to weight loss and limb atrophy. The Plan denied your request. The Plan says while the 
prosthetist alleges that the enrollee is a K3 ambulator, the clinical documentation does not support this. While 
the enrollee's doctor states that the enrollee is a K2 ambulator, since the enrollee has been using a walker since 
amputation. This is not consistent with K3 ambulatory function. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records provided by the enrollees medical doctor state the 
enrollee is a K2 ambulator. Based on this information, we decided that Medicare rules for coverage of 
prosthetic leg replacement have not been met. Therefore, we decided that the Plan does not have to pre-approve 
an addition, endoskeletal system, below knee, flexible protective outer surface covering system (L5962), an 
addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature (L5968) and an 
all-lower extremity prosthesis, flex-walk system (L5981).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve reconstruction of mandible or maxilla, endosteal 
implant (21248) unlisted dental procedure code (41899) and anesthesia for intraoral procedures, including 
biopsy (00170). 
 
You asked the Plan to pre-approve the jaw surgery. You say that on February 7, 2022, codes 41899 and 00170 
was approved for surgery in the hospital due to the risks. You are only requesting the same at this time. The 
Plan denied your request. The Plan says the requested service is not covered by Medicare or the Plan. 
 
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. The Plan contract on page 4-
90 specifically says any services not listed are not covered. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
reconstruction of mandible or maxilla, endosteal implant (21248) unlisted dental procedure code (41899) and 
anesthesia for intraoral procedures, including biopsy (00170).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a respiratory assist device (E0470), provided on May 30, 2022, to July 
30, 2022. 
 
You asked the Plan to pay for a respiratory assist device. You say that the item is medically necessary. The 
Plan denied your request. The Plan says that the provider is not licensed in the state/territory the services were 
provided in. 
 
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. The documentation provided in the case file does not support that the treating 
physician had an inactive license on the date of service in question. Review of the Medicare website shows that 
the provider participates in Medicare and has an active medical license in the Virgin Islands. No other 
documentation was submitted to support that the provider is prohibited from billing Medicare or Medicare 
health plans for services rendered. As such, the Plan's denial is not substantiated in this case. Therefore, we 
decided that the Plan has to pay for a respiratory assist device (E0470), provided on May 30, 2022, to July 30, 
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.