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

 
We decided that the Plan does not have to pre-approve an electrical connection (E2310). 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested feature is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the item. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the patient does not require non-proportional input devices (e.g., sip and puff, head array, etc.). The 
patient 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 patient's upper functional ability as evidenced by being 
independent for feeding should be sufficient to control any power options through their own switches. The 
documentation does not reveal that the E2310 is medically necessary as it exceeds the patient's needs. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an electrical connection (E2310).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sildenafil Citrate. 
 
You asked the Plan to pre-approve Sildenafil Citrate. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 Sildenafil Citrate.   
Benefits for Sildenafil Citrate may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
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 do not agree with the denial. 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 have an 
eligible condition that meets 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from April 18, 2022, to 
April 21, 2022. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
submitted supporting documentation for reconsideration of DRG adjustment. The Plan denied your request. 
The Plan says the review did not find sufficient documentation to clinically validate the diagnosis of A41.89. 
 
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 DRG 871. 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 services at issue in this case were not supported by the medical records. Our physician reviewer found 
that in this case, there was no clinical or laboratory evidence of sepsis. The review has determined that the 
documentation did not support diagnosis code A41.89. The records more support DRG175 in this case.  
 
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 rendered from April 18, 2022, to April 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77012 billed for date of service September 
21, 2022. 
 You asked the Plan to pay for procedure code 77012. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 77012 is bundled into payment for code 
32408. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 77012 
is a column II code to column I code 32408. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 77012 billed for date of service September 21, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 17, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says with the information 
we have, we cannot determine how the member came to the servicing provider, or whether the services are 
medically necessary. 
 
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 the office visit have been met. Medical 
records were not provided. Therefore, we decided that the Plan does not have to pay for an office visit provided 
on August 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the stair lift you purchased on May 18, 2022. 
 
You asked the Plan to pay for the stair lift. You say that your doctor gave you a prescription for this device.  
You said that you are entitled to 50% reimbursement. The Plan denied your request. The Plan says this is not a 
covered item. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for the stair lift you purchased on May 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from April 19, 2021, to 
April 22, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the clinical documentation does not support 
that A41.9 impacted the hospital admission. 
 
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 DRG 551. 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 services at issue in this case were not supported by the medical records. Our physician reviewer found 
that there was no clinical or laboratory evidence of sepsis. The review has determined that the documentation 
did not support diagnosis code A41.9 - sepsis, unspecified organism. The records supported the reporting of 
DRG 552.  
 
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 rendered from April 19, 2021, to April 22, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 30, 2022 to 
June 28, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you timely submitted the 
required Notice of Admission. The Plan denied your request. The Plan says the claim has not been billed with 
the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 30, 2022 to June 
28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73020 billed for date of service November 
24, 2022. 
 You asked the Plan to pay for procedure code 73020. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 73020 is bundled into payment for code 
73030. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 73020 
is a column II code to column I code 73030. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 73020 billed for date of service November 24, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 You asked the Plan to pre-approve Hyalgan. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc or Supartz FX 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 Hyalgan. Our reviewer says that 
Hyalgan is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drugs or any reason they 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and a segmental 
gradient pressure pneumatic appliance, half leg (E0673) provided on October 3, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and an appliance. You say that you disagree 
with the denial and have submitted medical records for review. The Plan denied your request. The Plan says 
Pneumatic compression devices are not covered by Medicare when the place of service is an ambulatory 
surgical center. 
 
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. The records show you billed with place of 
service 24, which is an ambulatory surgical center. Medicare rules state that for durable medical equipment to 
be covered, it must be appropriate and be needed for use inside the home. Medicare does not consider an 
ambulatory surgical center a home. Therefore, we decided that the Plan does not have to pay for a pneumatic 
compression device (E0675) and a segmental gradient pressure pneumatic appliance, half leg (E0673) provided 
on October 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2311, E2313, E2377), gel 
pads (K0108), and a power seat elevation feature (E2300) for an approved power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that these features are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when medically 
necessary. Items that are not primarily medical in nature are 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 wheelchair accessories. Our 
reviewer says that these items are not medically necessary. Our physician reviewer found the records show the 
enrollee has sufficient strength to operate the power features using the standard switches. The requested gel 
pads and power seat elevation feature are not primarily medical in nature and are non-covered. 
 
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 wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable controller (E2311, E2313, E2377), gel pads (K0108), and a 
power seat elevation feature (E2300) for an approved power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 47610 billed for date of service September 
27, 2022. 
 
You asked the Plan to pay for procedure code 47610. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says the available records do not support the service 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 47610 is: Cholecystectomy with exploration of common 
duct. 
 
We asked our coder 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 procedure code 47610. Our reviewer says that the code at 
issue does not meet criteria for payment. Our reviewer found that the procedure report states that the 
gallbladder was dissected from the surrounding tissues; however, it does not specify that the gallbladder was 
excised completely. A specimen is mentioned but it is not specified that it was the entire gallbladder. The 
available documentation does not support code 47610.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 47610 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 47610 billed for date of service September 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient behavioral health stay. 
 
You asked the Plan to pre-approve continued inpatient behavioral health. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the enrollee is not receiving active treatment and the 
treatment being provided is not expected to be of clinical benefit. The enrollee appears to be receiving custodial 
care. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient behavioral health. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee was 
admitted to the acute inpatient psychiatric hospitalization on March 10, 2023, with major neurocognitive 
disorder, due to Alzheimers disease with behavioral disturbance. Based upon review the records provided it 
was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did 
not have suicidal or homicidal ideation, auditory or visual hallucinations. The enrollee was compliant with 
treatment while not showing any acute threats to safety. It did not appear medically necessary and reasonable to 
have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the 
dates in question as she did not have dangerousness to self or others and was compliant with her treatment. The 
health plans denial of continued inpatient psychiatric services is appropriate. This enrollee did not appear to 
require inpatient mental health treatment beyond the date in question as she was not a danger to herself or 
others and does not have auditory or visual hallucinations. It did not appear that active treatment was taking 
place beyond the date in question. It did not appear that the services were reasonably expected to improve the 
enrollee's condition or for the purpose of diagnosis beyond the date in question. The reviewer is unable to find 
an individualized treatment plan in the record. It did appear that the records were supervised and evaluated by a 
physician. Based upon review the records provided for the admission of this enrollee does not meet the criteria 
for March 29, 2023, forward as the enrollee was not shown to be a danger to herself or others, delusions, 
auditory or visual hallucinations noted. She was cooperative/compliant with treatment while not showing any 
threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient behavioral health have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued inpatient behavioral health stay.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on September 26, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed.  Therefore, we decided that the Plan does not have to pay for the laboratory services related to end-stage renal 
disease (ESRD) provided on September 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (code D5110). 
 
You asked the Plan to pre-approve complete denture - maxillary. You say that complete denture - maxillary is 
medically necessary. The Plan denied your request. The Plan says complete denture - maxillary is not a covered 
dental benefit. 
 
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 
complete denture - maxillary (code D5110).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (U0003, U0005) provided on October 11, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were medically necessary and 
reasonable. The Plan denied your request. The Plan says that criteria are not met for these services. 
 
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 Plan has not substantiated their denial with a clear explanation 
including supporting documentation and a relevant citation. Therefore, we decided that the Plan has to pay for 
laboratory services (U0003, U0005) provided on October 11, 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.