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

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options and accessories. 
 
You asked the Plan to pre-approve Group 3 power wheelchair. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the requested 
power options, and a Group 3 power wheelchair with no power options would be considered for coverage 
instead. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered if certain criteria are met. If the base power wheelchair is not covered, all related 
accessories will also be denied. 
 
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 Group 3 power wheelchair. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee does not have a significant enough neurological condition that 
would require power tilt. Additionally, the enrollee is noted to have trace lower extremity edema and there is 
no indication that the enrollee would require power elevating leg rests for management of lymphedema. 
Therefore, the Group 3 power wheelchair with multiple power options is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. As the base power wheelchair does not meet 
coverage criteria, all related accessories are also denied. Based on this information, we decided that Medicare 
rules for coverage of Group 3 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Group 3 power wheelchair with multiple power options and accessories.
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 you need rehab to help your condition because if left 
untreated it can cause other health problems. The Plan denied your request. The Plan says an IRF admission is 
not medically necessary, and your needs can be met at a lower level of care. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital admission after a right 
reverse shoulder arthroplasty with tenodesis. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service 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. 
 
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 care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the procedure is currently approved as an ambulatory procedure. There is 
no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. 
 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 care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital admission after a right reverse shoulder 
arthroplasty with tenodesis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that that the enrollee has been medically cleared for an 
IRF admission, and you are requesting reconsideration based on the records submitted. The Plan denied your 
request. The Plan says the enrollee does not meet Medicare guidelines for service in an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program.  While the enrollee may have 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 the 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH criteria and is 
stable and ready for transfer to the LTACH. The Plan denied your request. The Plan says admission to an 
LTACH is not medically necessary. 
 
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 that there are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the health plan. The health plan has approved ongoing 
care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, 
and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively 
only on an inpatient basis. 
 
 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Lite test strips 
 
You asked the Plan to pre-approve the diabetic testing supplies. You say that you are appealing the denied test 
strips. The Plan denied your request. The Plan says the requested brand is not a covered diabetic testing supply. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufactures as 
preferred brands and may limit the DME to only those preferred brand.  
 
We looked at the file, Medicare rules, and the Plans rules. Based on this information, we decided that the Plans 
rules for coverage of the diabetic testing supplies have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the FreeStyle Lite test strips
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99291 billed for date of service July 17, 2022. 
 
You asked the Plan to pay for the billed services. You say that the relationship allows for the use of modifier 
25. The Plan denied your request. The Plan says that the payment for this service is included in the fee for the 
procedure. 
 
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. 
 
We looked at the file and the rules. In this case, the Plan has not provided any other billed codes or claim 
information that shows the code at issue is included in the payment for other services. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request.  Therefore, we decided that the Plan has to pay for procedure code 99291 billed for date of service July 
17, 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to the IRF is required as the enrollee's 
needs cannot safely be met at a lower level of care. The Plan denied your request. The Plan says the enrollee 
does not meet the Medicare criteria for admission to an inpatient rehabilitation 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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for sacral osteomyelitis. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the medical records support 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 the 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75820-26-59 billed for date of service June 
16, 2022. 
 
You asked the Plan to pay for the billed services. You say that the modifier is allowed to unbundle this service 
from code 37249. The Plan denied your request. The Plan says the code cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
We looked at the file and the rules. We find that the enrollee received transluminal balloon angioplasty services 
(codes 37248 and 37249), as well as thrombectomy services (code 37187). CPT Code 75820 is included in the 
payment for these services. The medical records provided do not show that the service billed with the -59 
modifier is a distinct procedural service. Based on this information, we decided that Medicare rules for 
coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 75820-26-59 billed for date of service June 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 
11, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that multiple procedures were rendered on this 
date of service. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service November 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit and services provided on 
March 15, 2022. 
 
You asked the Plan to pay for the emergency department visit and services. You say that emergency services 
were given to the enrollee, and you would like this claim to be reviewed. The Plan denied your request. The 
Plan says Medicare does not cover services that are not performed by a Medicare-certified provider. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items 
or services, a provider or supplier must be enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the emergency department visit and services have not been met. This provider is not part of the 
Medicare program and is not payable. Therefore, we decided that the Plan does not have to pay for the 
emergency department visit and services provided on March 15, 2022.
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 rehab is critical for the enrollee's life and health. You 
say returning home is impossible at this time as it would surely result in the enrollee's further deterioration and 
likely demise. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services you 
are requesting do not meet the requirements for approval. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 testing kit purchased on June 28, 
2022. 
 
You asked the Plan to pay for the at-home COVID-19 testing kit. You say that you acted in good faith after 
receiving the reimbursement form, and purchased the tests believing that you would be reimbursed by the Plan. 
The Plan denied your request. The Plan says at-home COVID-19 tests are not covered under your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
COVID-19 testing kit are an OTC item. The Plan does not offer a supplemental benefit covering this service. 
However, for future purchases, these can be obtained with participating providers and covered by Original 
Medicare when using your Medicare card rather than your Plan card. Therefore, we decided that the Plan does 
not have to pay for the at-home COVID-19 testing kit purchased on June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network office visit provided on 
June 23, 2021. 
 
You asked the Plan to waive the copayment for an out-of-network office visit. You say that you were told the 
provided was a in-network provider. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for out-of-network physician/practitioner services/Medicarecovered primary care doctor visit. 
 
You have been asked to pay a $40 copayment for an out-of-network office visit. This item/service falls within 
the out-of-network physician/practitioner services/Medicarecovered primary care doctor visit benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an out-of-network office visit provided on June 23, 2021.
Appeal type: Practitioner Services
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). 
 
You asked the Plan to pre-approve a Reactiv8 PNS Implantable Neurostimulation System. You say that the 
requested system is medically necessary for the enrollee. The Plan denied your request. The Plan says the 
request does not meet the Medicare or health plan coverage criteria. This type of nerve stimulator does not help 
the pain that the enrollee has. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Reactiv8 PNS Implantable 
Neurostimulation System. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident 
regarding a trial and failure of recent, reasonable, comprehensive less invasive conservative care measures. The 
enrollee is not clearly documented to have failed physical therapy. Moreover, there is limited published, large-
scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the 
noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested percutaneous implantation of 
neurostimulator electrode array; peripheral nerve, in this case, is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Reactiv8 PNS Implantable Neurostimulation System 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).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new replacement power wheelchair with multiple 
components. 
 
You asked the Plan to pre-approve a replacement power wheelchair and accessories. You say that the enrollee 
is not ambulatory and is unable to perform mobility related activities of daily living in the home setting. He is 
unable to do a functional weight shift. Given these factors, he qualifies for coverage of a replacement group 3 
power wheelchair with rehabilitation seating and power tilt in space. The Plan denied your request. The Plan 
says repairs were recently authorized for your current wheelchair. The power wheelchair you are asking for is 
the same or similar to the wheelchair you already have. 
 
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 enrollee has a power wheelchair. Medicare allows for coverage for repairs or a 
replacement device if the current power wheelchair is not functional, however per Medicare rules, only one 
wheelchair at a time is covered. Your current power wheelchair serves the same purpose as a replacement 
power wheelchair and accessories. The records show that the Plan approved repairs to the enrollees current 
power wheelchair. Therefore, we decided that the Plan does not have to pre-approve a new replacement power 
wheelchair with multiple components.