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

 
We decided that the Plan does not have to pre-approve a bath/shower chair (E0240) and a total electric hospital 
bed (E0265). 
 
You asked the Plan to pre-approve a bath/shower chair and a total electric hospital bed. You say that these 
items are necessary. The Plan denied your request. The Plan says these items are not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  The rules also say that a total electric hospital bed is not covered.  
 
While a shower chair and total electric hospital bed may be appropriate in this case, neither the Plan nor 
Medicare offers coverage for these items. Therefore, we decided that the Plan does not have to pre-approve a 
bath/shower chair (E0240) and a total electric hospital bed (E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trigger point injections (20552 x 3, 20553 x 3). 
 
You asked the Plan to pre-approve trigger point injections. You say that the requested injections are medically 
necessary. The Plan denied your request. The Plan says the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that it is expected that trigger point injections would not 
usually be performed more often than three sessions in a three-month period. 
 
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 trigger point injections. Our reviewer 
says that the requested trigger point injections are not medically necessary. Our physician reviewer found the 
provided documentation indicates that the enrollee has been receiving trigger point injections every six months, 
for years. The reviewer found that the requested injections exceed the the allowed frequency. Therefore, the 
reviewer found that the requested trigger point injections are 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 trigger point injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve trigger point injections (20552 x 3, 20553 x 3).
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for altered mental status, weakness, and upper extremity 
cellulitis. The enrollee's medical problems are stable, and 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. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive orthodontic treatment (D8090). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting an expedited 
reconsideration due to physical and mental pain that causes 24 hours of life-threatening pain. You say you are 
working with several government agencies to overturn this decision. The Plan denied your request. The Plan 
says the request does not meet Medicare or the Plan's coverage criteria. 
 
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 pre-approve 
comprehensive orthodontic treatment (D8090).
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 enrollee would benefit from inpatient 
rehabilitation to improve overall safety and functional mobility prior to returning home with family. The Plan 
denied your request. The Plan says the enrollee's records do not show the need for an intensive team for care, 
services needed can be provided safely in other settings, skilled nursing facility, home with home health 
services or home with outpatient therapy. 
 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. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88360 billed for date of service September 
19, 2022. 
 You asked the Plan to pay for procedure code(s) 88360. You say that this service was necessary and is 
supported as billed. 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 code(s) 88360. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 88360. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88360 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88360 billed for date of service September 19, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service May 20, 
2022. 
 
You asked the Plan to pay for procedure code 0003A. You say that this claim should be paid. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service May 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pain management services to be provided by an  
out-of-network provider. 
 
You asked the Plan to pre-approve pain management services to be provided by an out-of-network provider. 
You say that you have been going to this provider for over 20 years and you have had the most success with 
this provider. The Plan denied your request. The Plan says you or your physician have not provided clinical 
information to indicate the services you are requesting cannot be provided by an in-network provider. You 
were previously approved for continuity of care visits with this provider to give you time to transition to an 
in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve pain 
management services to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 You asked the Plan to pre-approve Eylea. You say that Eylea is medically necessary. The Plan denied your 
request. The Plan says a trial of Avastin is required before alternatives can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Eylea. Our reviewer says that Eylea is 
not medically necessary. Our physician reviewer found the records do not show a trial of the plan preferred 
drug or any reason it would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs provided to you from October 4, 2022, to October 
6, 2022. 
 
You asked the Plan to pay for the drugs. The Plan denied your request. The Plan says these drugs are not 
covered under your Part B plan. 
 
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 pay for the drugs provided to you from 
October 4, 2022, to October 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you have coronary artery disease which is a 
qualifier for these benefits. The Plan denied your request. The Plan says the criteria for eligibility have not been 
met. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not meet all the 
required criteria. Therefore, we decided that the Plan does not have to pre-approve special supplemental 
benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medium, adult sized, protective underwear/pull-on, 
medium size, each (T4526). 
 
You asked the Plan to pre-approve the incontinence supplies. You say that you feel this should not be denied 
because you had them last year and it is unfair that you cannot get them n ow. The Plan denied your request. 
The Plan says the Plan will approve only 1 size (large) of adult pull on because two sizes is considered a 
duplicate and excessive. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the Plan has approved large, adult sized protective underwear/pull-on, each (T4527). The 
Plan also approved large disposable under pads (T4541). The large, adult sized protective underwear/pull-on, 
large size, each (T4527) serves the same purpose as the incontinence supplies. Therefore, we decided that the 
Plan does not have to pre-approve medium, adult sized, protective underwear/pull-on, medium size, each 
(T4526).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VELA disability chair (E1399). 
 
You asked the Plan to pre-approve the VELA disability chair. You say that you use a regular office chair at 
home for mobility, but due to your obesity, the chair breaks. This model is thicker, and you believe it will hold 
your weight. The Plan denied your request. The Plan says the VELA disability chair is not covered. 
 
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 the VELA disability chair (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on October 19, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64479 provided on September 14, 2022. 
 
You asked the Plan to pay for procedure code 64479. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 64479 is not supported in the medical record. This code has a bilateral surgery indicator of 1. This means the code should be reported with 1 unit of service and modifier 50 (bilateral modifier) to be 
considered for payment. Therefore, we decided that the Plan does not have to pay for procedure code 64479 
provided on September 14, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a take-home supply of methadone; up to 7 additional day supply 
(code G2078) provided on November 21, 2022. 
 
You asked the Plan to pay for a take-home supply of methadone; up to 7 additional day supply. You say that 
you have been enrolled in the Medicare program to provide Opioid Treatment Program (OTP) services since 
January 1, 2020. The Plan denied your request. The Plan says that the claim for these drugs was billed by the 
physician, not the opioid treatment program (OTP) facility. The rules say that only an entity enrolled with 
Medicare as an OTP can bill these codes. 
 
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. Specifically, the OTP is the billing provider and is Substance Abuse and Mental 
Health Services Administration (SAMHSA) certified. The rules cited by the Plan do not provide a valid reason 
to deny this claim given that the OTP meets the Medicare coverage criteria. This provider continues to use the 
professional claim, which is allowed under Medicare rules. Therefore, we decided that the Plan has to pay for a 
take-home supply of methadone; up to 7 additional day supply (code G2078) provided on November 21, 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. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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'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 
hematoma of the thigh. She is now medically stable with 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. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve physician's services to be provided by an out-of-network provider. You say 
that the services are medically necessary. The Plan denied your request. The Plan says you must use network 
providers to get your medical care and services. If you go elsewhere without proper authorization you will have 
to pay in full. The only exceptions are emergencies, urgently needed services when the network is not 
available (that is, in situations when it is unreasonable or not possible to obtain services in-network), out-of-
area dialysis services, and cases in which the Plan authorizes use of out-of-network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by an out-of-network provider.