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

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2377, E2313). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that the upgraded electronics are 
medically necessary. The Plan denied your request. The Plan says that it is not medically necessary to control 
the requested power options through the joystick. 
 
The Plan follows Medicare rules. Medicare rules say that a harness (E2313) describes all of the wires, fuse 
boxes, fuses, circuits, switches, etc. that are required for the operation of an expandable controller. It also 
includes all the necessary fasteners, connectors, and mounting hardware. The rules also 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. 
 
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 upgraded electronics. Our reviewer 
says that the coverage criteria has not been met. Our physician reviewer found that the provided records 
document that you have 4-/5 bilateral upper extremity strength and are independent with feeding, meal 
preparation, grooming, and dressing thus indicating you have adequate upper extremity strength and function to 
operate the wheelchair's power options with their own 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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics (E2311, E2377, E2313).
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 can tolerate 3 hours of therapy 5 days a 
week. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and the 
enrollee's needs can be met in other settings. 
 
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 enrollee does not need physician supervision 3 times a week or intensive 
therapy 3 hours a day and 5 days per week with a multidisciplinary approach in an IRF. While the enrollee may 
benefit from physical and occupational therapy the enrollee's needs can be provided in an alternate setting such 
as skilled nursing facility. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two (2) office visits (99213, 99214) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the enrollee is not in active treatment with the 
requested provider. The enrollee must use in-network providers for all care/services. 
 
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 
two (2) office visits (99213, 99214) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies provided on September 13, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that the proof of 
delivery did not include an order number or details to corroborate the delivery ticket submitted. Of note, the 
proof of delivery is not itemized to indicate the specific supplies. 
 
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 Plan argues that the proof of delivery did not include an order number or 
details to corroborate the delivery ticket submitted, and the proof of delivery is not itemized to indicate the 
specific supplies. However, the records contain an itemized packing slip dated September 13, 2022, with the 
same tracking number as the delivery ticket dated September 17, 2022. As such, the records support that the 
items at issue in this case were delivered. Therefore, we decided that the Plan has to pay for the electrical 
stimulator supplies provided on September 13, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental, investigational, and unproven. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this is considered an experimental/investigational procedure. It is the subject of ongoing clinical 
trials. Therefore, the request is deemed not medically reasonable and 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve radiofrequency ablation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory PCR (polymerase chain reaction) panel 
provided on December 12, 2022. 
 
You asked the Plan to pay for the respiratory PCR panel. You say that this test was referred by the enrollee's 
physician and is supported in the medical record. The Plan denied your request. The Plan says this panel was 
not billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a respiratory pathogen panel cannot be 
unbundled and billed as individual components regardless of the fact that the test reports multiple individual 
pathogens and/or targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of respiratory pathogen testing have not been met. Specifically, the records show that a single panel 
was ordered and performed, but this service was billed by reporting individual components. Therefore, we decided that the Plan does not have to pay for the respiratory PCR (polymerase chain reaction) panel provided 
on December 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator 
electrode array, peripheral nerve (excludes sacral nerve) (64555) and implantable neurostimulator, pulse 
generator, any type (L8679). 
 
You asked the Plan to pre-approve an implantable neurostimulator. You say that the enrollee would be an 
excellent candidate for the percutaneous electrical nerve stimulation (PENS) unit to help with chronic pain and 
reduce the use of narcotics. The Plan denied your request. The Plan says Medicare does not allow coverage of 
an electric stimulator that works behind-the-ear to treat back pain. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of an implantable neurostimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a percutaneous implantation of neurostimulator electrode array, peripheral nerve (excludes 
sacral nerve) (64555) and implantable neurostimulator, pulse generator, any type (L8679).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee can adequately receive the care needed for ongoing ventilator weaning in the current location and is 
not required to discharge elsewhere to receive ongoing acute level care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee is improving but still requires acute care 
services before transitioning to 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from March 16, 2022, to 
March 21, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records support the DRG billed. The Plan denied your request. The Plan says the determination to 
remove principal diagnosis code A41.59, Other Gram-negative sepsis from the claim and assign ICD-10 CM 
diagnosis code K56.51, Intestinal adhesions [bands], with partial obstruction as principal diagnosis consistent 
with documentation received remains upheld. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.59, Other Gram-
negative sepsis. 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 pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that the documentation does not support that the 
inpatient care is payable as billed.  Our physician reviewer found that in the emergency department (ED)  the 
enrollee's heart rate was106, white blood cells (WBC) of 14.78 and lactic acid of 2.2. The values promptly 
improved after treatment in the ED. Also, the documentation did not show a Glasgow Coma Score below 15 or 
persistent hypotension with a mean arterial pressure (MAP) less than 70 after initial fluid challenge in the ED. 
There was no clinical or laboratory evidence of sepsis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from March 16, 2022, to March 21, 2022, at the DRG originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pressure-reducing support surface to be provided at 
the in-network benefit level by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve pressure-reducing support surface. You say that this is medically necessary 
for the enrollee. The Plan denied your request. The Plan says this provider is out-of-network with the Plan and 
this item can be obtained within the Plan network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that enrollees may choose to receive care from an out-of-network provider, but the share of costs for 
covered items/services may be higher. 
 
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 at the in-network benefit level. Therefore, we decided that the Plan 
does not have to pre-approve a pressure-reducing support surface to be provided at the in-network benefit level 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan (78813). 
 
You asked the Plan to pre-approve the PET scan. You say that the services should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as the 
requested services are experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that the record provided does not establish 
the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements 
of the coverage criteria are not satisfied.  The requested service is not recommended. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan (78813).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller, including all related 
electronics and mounting hardware, upgrade provided at initial issue (E2377), harness for upgrade to 
expandable controller, including all fasteners, connectors and mounting hardware, each (E2313), and electronic 
connection between wheelchair controller and two or more power seating system motors, including all related 
electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (E2311). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for these items. 
 
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 DME. Our physician reviewer 
found the enrollee does not require non-proportional input devices (e.g., sip and puff, head array, etc.). The 
enrollee does not require a separate display (i.e., for alternate control devices), other electronic devices (e.g., 
control of an augmentative speech device or computer through the chair's drive control), or an attendant 
control. The documentation does not support that it is medically necessary to control the requested power 
options through the joystick (drive interface). The enrollee's upper extremity strength should be sufficient to 
control any power options through their own switches. The documentation does not reveal that E2377, E2313 
and E2311, are medically necessary per Local Coverage Article:  Wheelchair Options/Accessories - Policy 
Article (A52504) and the  Social Security Act, Section 1862 (a)1(A) and the 42 CFR Section 411.15(k), as 
Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or 
treatment of illness or injury or to improve the functioning of a malformed body member. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the expandable controller, including all related electronics and mounting hardware, upgrade 
provided at initial issue (E2377), harness for upgrade to expandable controller, including all fasteners, 
connectors and mounting hardware, each (E2313), and electronic connection between wheelchair controller 
and two or more power seating system motors, including all related electronics, indicator feature, mechanical 
function selection switch, and fixed mounting hardware (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device (E0730) provided September 12, 2022. 
 
You asked the Plan to pay for the TENS device. You say that according to the prescription, the prescribing 
physician recommends an extended lifetime use of equipment as the enrollee is diagnosed with chronic pain 
and compromised mobility without the option for surgical correction. The Plan denied your request. The Plan 
says evidence of misrepresented services. 
 
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 a valid proof of delivery, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the documentation submitted did not include a 
proof of delivery, or a delivery ticket. 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 
transcutaneous electrical nerve stimulation (TENS) device (E0730) provided September 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the associated acute inpatient hospital admission. 
 
You asked the Plan to pre-approve acute inpatient hospital admission. You say that the enrollee needs this 
surgery. The Plan denied your request. The Plan says the inpatient admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for an inpatient admission are met in this 
case. Our physician reviewer found the associated procedure is currently approved as an ambulatory procedure. 
There is no need to prospectively approve the inpatient admission. Therefore, the reviewer found that the 
associated inpatient admission 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 acute inpatient hospital admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the associated acute inpatient hospital admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the miscellaneous wheelchair component or accessory, 
privacy flap (K0108). 
 
You asked the Plan to pre-approve the privacy flab. You say that you are requesting approval of this claim as 
the enrollee is currently at high risk of falls and/or injury without the appropriate medical equipment. The Plan 
denied your request. The Plan says this item does not primarily serve a medical purpose and is not covered. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the privacy flab have not been met. Therefore, we decided that the Plan does not have to pre-
approve the miscellaneous wheelchair component or accessory, privacy flap (K0108).