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

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device. 
 
You asked the Plan to pre-approve the requested device. You say that the enrollee struggles with a chronic 
cough. The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall 
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve a high frequency chest wall oscillation device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee does not need to stay in an acute hospital 
when the enrollee needs physical therapy, and it is not helping the enrollee in their daily activities. The Plan 
denied your request. The Plan says based upon the enrollee's current level of function, the enrollee does not 
require an intensive, complex, multidisciplinary approach to daily therapy. The enrollee's ongoing skilled 
therapy and nursing needs can be provided at a lower level of care such as at a skilled nursing facility, on an 
intermittent basis at home with home health care, or in a long-term care 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 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. The 
enrollee was admitted for a stroke. Medical problems are stable. There are no complex nursing or rehabilitation 
needs.  
 
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. Medically 
necessary care can be provided in a different level of care. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair access power seating system tilt only 
(E1002), an electronic connection between wheelchair controller and one power seating system motor (E2310), 
a harness for an upgrade to an expandable controller (E2313) and an expandable controller (E2377). 
 
You asked the Plan to pre-approve power wheelchair accessories. You say that the requested accessories are 
medically necessary. The Plan denied your request. The Plan says you do not have a diagnosis that causes you 
to have increased risk of lower extremity spasticity. Overall, this indicates that you can functionally shift 
weight in a wheelchair and therefore do not require a power tilt option. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve power wheelchair accessories. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found you do not require a 
ventilator, a non-proportional input device, a separate display, other electronic devices or an attendant control. 
Furthermore, your upper extremity strength and function, support that you can control any power options 
through their own switches. There is no evidence of intermittent catheterization. The documentation does not 
support that you are unable to perform a functional weight shift. The documentation does not indicate objective 
evidence of spasticity on a BLE physical exam that needs a power seating system for management therefore the 
request for power recline exceeds your medical needs. You do not require power tilt and do not need to control 
any power options through a joystick. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a wheelchair access power seating system tilt only (E1002), an electronic 
connection between wheelchair controller and one power seating system motor (E2310), a harness for an 
upgrade to an expandable controller (E2313) and an expandable controller (E2377).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits 
 
You asked the Plan to pre-approve physical therapy. You say that the enrollee needs the therapy to prevent 
worsening of edema and wounds and keep patient mobile. The Plan denied your request. The Plan says the 
denial of authorization for this service is correct, because these additional 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 the records do not demonstrate that the unique skills of a professional 
therapist are required to provide treatment safely and effectively. The enrollee has extensive education in her 
wound care. The wound care is not complex and does not require ongoing skilled therapy. 
 
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  additional physical therapy visits
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of impacted tooth - soft tissue (D7220) and removal 
of impacted tooth - partially bony (D7230 x2) provided on February 10, 2022. 
 
You asked the Plan to pay for removal of impacted tooth - soft tissue and removal of impacted tooth - partially 
bony. You say that you were not informed that the services would not be covered. The Plan denied your 
request. The Plan says the services at issue are not covered 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. 
 
   
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 pay for removal 
of impacted tooth - soft tissue (D7220) and removal of impacted tooth - partially bony (D7230 x2) provided on 
February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified mass spectrometry, billed with code 83789. 
 
You asked the Plan to pay for the unspecified mass spectrometry. You say that this is medically necessary 
testing. The Plan denied your request. The Plan says this is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the unspecified mass spectrometry have not been met. Specifically, we find that the testing 
described by the billed code is considered specimen validity testing which is not separately payable. Therefore, 
we decided that the Plan does not have to pay for the unspecified mass spectrometry provided, billed with code 83789.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denied IRF services. The Plan 
denied your request. The Plan says the documentation provided shows that there are no acute medical needs 
that requires medical monitoring by a rehabilitation doctor. The enrollee needs can be met at a lower level of 
care such as a skilled nursing facility, outpatient rehabilitation facility, or a home with home health. 
 
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 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. The 
enrollee was admitted for a stroke. Medical problems are stable. There are no complex nursing or rehabilitation 
needs.  
 
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. Medically 
necessary care can be provided in a different level of care. 
 
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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 21, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service March 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. You say 
charges are not required for pre-authorization. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on March 15, 2022, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport (A0429) and ground mileage (A0425) provided on May 19, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee's hospice election was revoked 
on May 18, 2021. You also say that you just want this to be taken care of. The Plan denied your request. The 
Plan says the enrollees claim would be covered under Original Medicare as it is responsible for coverage of 
Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The 
Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and 
to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 18, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance service, 
basic life support, emergency transport (A0429) and ground mileage (A0425) provided on May 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage. 
 
You asked the Plan to pre-approve additional mileage. You say that you need to be seen for a consultation, and 
this is the closest dental office. The Plan denied your request. The Plan says this request exceeds the Plan's 
milage limit of 60 miles. The Plan also says that transportation trips that exceed the 60-mile limit are not 
covered under the Routine Transportation benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 60 miles.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three additional acupuncture visits. 
 
You asked the Plan to pre-approve the acupuncture visits. You say that the acupuncture alleviates your pain 
and inflammation. The Plan denied your request. The Plan says records do not support the need for additional 
acupuncture visits. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case. 
 
 
  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 acupuncture visits. Our reviewer says 
that the service at issue in this case is not medically reasonable or necessary. Our physician reviewer found that 
the records provided by the practitioner did not support additional acupuncture therapies. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acupuncture visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve three additional acupuncture visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable control system. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee is able to control the power options using their own switches. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 
The file shows that an expandable control system was requested. 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 services. Our physician reviewer found that in this case, the enrollee has a 
neurologic disorder with functional deficits. The requested electrical accessories are not medically necessary as 
the member does have use of the upper extremity and can operate and control the power options using the 
switches that are included in the basic wheelchair. 
 
The file shows that gel arm pads were requested. The approved wheelchair includes arm rests, which means 
they are not separately payable. The documentation does not show that standard arm rests are not able to meet 
the enrollee's needs. We looked at the physician's review, the file, and Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of the requested services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an expandable control system.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 22, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power seat elevation system (E2300) and electronic 
connection (E2310). 
 
You asked the Plan to pre-approve the wheelchair equipment. You say that this is medically reasonable and 
necessary. The Plan denied your request. The Plan says Medicare does not cover these accessories per the 
Medicare rules. 
  
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. Medicare 
rules say that if a wheelchair has an electrical connection device described by code E2310 or E2311 and if the 
sole function of the connection is for a power seat elevation or power standing feature, it will be denied as non-
covered. Based on this information, we decided that Medicare rules for coverage of the wheelchair equipment 
have not been met. Therefore, we decided that the Plan does not have to pre-approve power seat elevation 
system (E2300) and electronic connection (E2310).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revision mastectomy (removal of breast tissue) for 
gender affirmation. 
 
You asked the Plan to pre-approve revision mastectomy. You say that you feel this procedure is necessary to 
your health. The Plan denied your request. The Plan says the requested services 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 revision mastectomy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have previously undergone top gender affirming surgery. The requested 
procedure is to address cosmetic concerns regarding scars and fullness of appearance. The documentation does 
not support that medical necessity or reasonableness has been met. Therefore, you do not meet criteria for the 
requested services. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revision mastectomy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve revision mastectomy (removal of breast tissue) for gender affirmation.