Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99217) provided on October 22, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says code 99217 is not 
payable in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician may not bill the hospital 
observation discharge management code (code 99217) or an outpatient/office visit for the care provided while 
the patient received hospital outpatient observation services on the date of admission to inpatient status. 
 
We looked at the file and Medicare rules. In this case, it is inappropriate to bill code 99217 for the observation 
discharge services, as the enrollee was was admitted to inpatient status. 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 pay for the services (99217) provided on October 22, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient therapy services provided from June 1, 2021, to 
June 10, 2021. 
 
You asked the Plan to pay for therapy services. You say that medical records were previously submitted for 
these services. The Plan denied your request. The Plan says no medical records were received to support these 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of therapy services have been met. 
Specifically, no medical records were provided to support that these services were reported correctly and were 
medically necessary and reasonable. Therefore, we decided that the Plan does not have to pay for outpatient 
therapy services provided from June 1, 2021, to June 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery back-up for a continuous positive airway 
pressure (CPAP) machine (A9270). 
 
You asked the Plan to pre-approve a battery back-up for a CPAP machine. You say that due to health issues, 
you need a battery backup because the power goes out frequently. The Plan denied your request. The Plan says 
durable medical equipment is equipment which can withstand repeated use; is primarily and customarily used 
to serve a medical purpose; generally, is not useful to a person in the absence of an illness or injury; and is 
appropriate for use in the home. Alternative power sources are not considered by Medicare as durable medical 
equipment. Medicare does not allow payment for power generators or alternative power sources needed in the 
event of power outages. 
 
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 a battery back-up for a continuous positive airway pressure 
(CPAP) machine (A9270).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. You have a diagnosis of chronic obstructive pulmonary disease (COPD) and stage IV chronic 
kidney disease. It appears that the acute hypercarbic respiratory failure was due primarily to volume overload 
and pulmonary edema, with an unknown role of COPD. If you do have chronic carbon dioxide (CO2) 
retention, you may benefit from bilevel positive airway pressure (BiPAP) during sleep as an outpatient. If you do have severe COPD, average volume-assured pressure support (AVAPS) and a backup rate can be provided 
via BiPAP. Medicare does not cover a home ventilator when used as BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro Motion G orthosis. You say that the device is medically 
necessary for the enrollee. The Plan denied your request. The Plan says there is not enough medical evidence 
that shows the MyoPro is reasonable and necessary to improve the function of the enrollee's right arm. 
 
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 MyoPro Motion G orthosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro Orthosis is not known to be effective, based on scientific 
evidence, professional standards and expert opinion, in improving health outcomes. The MyoPro is not the 
standard of care for this enrollee's condition or in widespread use for this enrollee's condition based on 
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the 
long-term outcomes for this enrollee. There is insufficient evidence in the literature that this device will 
increase participation in bimanual activities. 
 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 MyoPro Motion G orthosis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro Motion G orthosis (L8702).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an OptiMesh Spineology Expandable Cage System. 
 
You asked the Plan to pre-approve an OptiMesh Spineology Expandable Cage System. You say that the 
records provided support the need for the OptiMesh system. You say that the OptiMesh system is not 
experimental and has been covered by other carriers, including Medicare. The Plan denied your request. The 
Plan says medical studies have not proven that the requested item is helpful for treatment of the enrollee's 
health problem. 
 
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 an OptiMesh Spineology Expandable 
Cage System. Our reviewer says that an OptiMesh Spineology Expandable Cage System is not considered 
medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not 
evident regarding the requested surgical procedure including autograft and/or allograft. 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.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an OptiMesh Spineology Expandable Cage System have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an OptiMesh Spineology Expandable Cage 
System.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve Gemtesa. You say that the requested drug is medically necessary for the 
enrollee's treatment. The Plan denied your request. The Plan says the requested drug is considered self-
administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug 
plan. The Plan also says the requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device, elbow, wrist, hand with single or double upright(s), includes microprocessor, sensors, all components, 
and accessories, custom fabricated (L8701). 
 
You asked the Plan to pre-approve the MyoPro Orthosis. You say that the device is medically necessary. The 
Plan denied your request. The Plan says the MyoPro Orthosis is not approvable by this enrollee's health plan 
because it is still being studied to establish clinical effectiveness and long-term safety of the device. 
 
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 MyoPro Orthosis. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro Orthosis is not known to be effective, based on scientific evidence, 
professional standards, and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for this enrollee's condition or in widespread use for this enrollee's condition based on scientific evidence. 
There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes 
for this enrollee. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 MyoPro Orthosis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a powered upper extremity range of motion assist device, elbow, wrist, hand with 
single or double upright(s), includes microprocessor, sensors, all components, and accessories, custom 
fabricated (L8701).
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the IRF admission is not medically necessary, reasonable, and appropriate 
for the enrollee's condition. 
 
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 rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement however, the documentation doesnt support that they would meet criteria for admission to an 
acute inpatient rehabilitation facility. The enrollee can receive further services at 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 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that physical and occupational therapy is needed to gain 
function again, your father is unable to go up and down steps making it unable to return home. The Plan denied 
your request. The Plan says the records do not show the need for 24-hour rehabilitation nursing. 
 
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 while the medical record supports a need for physical and occupational therapy, there 
is no documented need for intensive rehabilitation service  
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 pay for inpatient care (99223) provided on August 13, 2022. 
 
You asked the Plan to pay for inpatient care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this code cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is inpatient hospital care. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, the record shows the 
enrollee was under outpatient observation at the time this service was provided. No observation code was 
reported. Based on this information, we decided that Medicare rules for coverage of inpatient care have not 
been met. Therefore, we decided that the Plan does not have to pay for inpatient care (99223) provided on 
August 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injections (20610) and fluoroscopic guidance (77002) 
provided from May 2, 2022, to May 25, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that these services are not considered 
experimental. You also say that they should be covered. The Plan denied your request. The Plan says the 
services are experimental and investigational. 
 
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 pay for the outpatient services. Our reviewer says 
that the outpatient services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation indicates that the obtained knee x-rays did not demonstrate 
significant degenerative joint changes. Therefore, the reviewer found that the outpatient services were 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 the outpatient services have not been met. Therefore, we decided that the Plan 
does not have to pay for the injections (20610) and fluoroscopic guidance (77002) provided from May 2, 2022, 
to May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit for observation (D9430), the application of a 
desensitizing medicament (D9910), and the resin based composite-four or more surfaces, posterior (D2394) 
provided on September 26, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
Additionally, code D2394 billed for tooth# 8 is not a correct code for an anterior tooth. 
 
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 office visit for observation and the 
application of a desensitizing medicament are not among those services covered under this benefit. 
Additionally, code D2394 billed for tooth# 8 is not a correct code for an anterior tooth.  Therefore, we decided that the Plan does not have to pay for the office visit for observation (D9430), the 
application of a desensitizing medicament (D9910), and the resin based composite-four or more surfaces, 
posterior (D2394) provided on September 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9810 billed for date of service July 21, 
2022, to August 24, 2022. 
 
You asked the Plan to pay for procedure code S9810. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9810 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9810 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9810 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9810 billed for date of service July 21, 2022, to August 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting SNF services for the enrollee. 
The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for SNF care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only in a 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 neurologist, cardiologist and primary physician 
all agree the inpatient rehabilitation is necessary. You say you need to regain strength. The Plan denied your 
request. The Plan says the IRF care is not medically necessary, and your needs can be met at a lower level of 
care such as a skilled nursing facility (SNF). 
 
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 you do not require the intensity of services provided at an IRF.  Specifically, you are 
not shown to be able to tolerate fifteen hours per week of rehabilitative services or to require regular physician 
evaluation. Your care needs can be met at a lower level of care (ex. SNF). 
 
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.