Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Insertion or replacement of permanent implantable 
defibrillator system, with transvenous lead(s), single or dual chamber (33249) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is no documented sustained VT, severe ischemic dilated 
cardiomyopathy, non-ischemic dilated cardiomyopathy or episode of cardiac arrest due to ventricular 
fibrillation. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The enrollee has 
ischemic cardiomyopathy and an ejection fraction of 45%. Our physician reviewer found that review of clinical 
documents does not show that the patient meets implant criteria for defibrillator insertion according to current 
guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Insertion or replacement of permanent implantable defibrillator system, with 
transvenous lead(s), single or dual chamber (33249) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be currently somewhat unstable and should only require short-
term acute care hospital services that can be safely completed at the current facility until more stable and 
appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to LTACH is not medically necessary as the 
enrollee is not yet stable enough for transfer and transfer would not be clinically advantageous at this time. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a custom dual cone (L5999) and prosthetic repair service (L7520) for 
an osseointegrated prosthetic limb provided on October 29, 2021. 
 
You asked the Plan to pay for a custom dual cone and prosthetic repair service. You say that the items and 
services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says that 
medical necessity rules for payment for the items and services at issue have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for a custom dual cone and prosthetic repair 
service. Our reviewer says that the requested items and services are considered medically reasonable and 
necessary in this case. Our physician reviewer found that the dual cone adapter sleeve is a custom-made 
cylinder designed to eliminate the edge transition between an osseointegrated implant and the adjacent dual 
cone. This sleeve is indicated for osteointegrated amputees whose stoma extends to the implant end and who 
experience significant stoma pain and swelling. This has been shown to reduce swelling and pain in 
osteointegration patients. The osseointegrated prosthetic limb has demonstrated a high success rate, with 
improved position and comfort. The majority of amputees who change from a traditional socket prosthesis to 
an osseointegrated prosthesis improve, both subjectively and objectively. 
 
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 custom dual cone and prosthetic repair service have been met. Therefore, we 
decided that the Plan has to pay for a custom dual cone (L5999) and prosthetic repair service (L7520) for an 
osseointegrated prosthetic limb provided on October 29, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (20526) provided on December 13, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE has been 
exceeded.  
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 20526 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 the 
services have not been met. Therefore, we decided that the Plan does not have to pay for the services (20526) 
provided on December 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on 
April 25, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid detailed written order. 
 
The Plan must follow Medicare rules. Medicare rules say that a standard written order (SWO) is required for all 
durable medical equipment (DME) and supplies. 
 We looked at the file and Medicare rules. The file shows that there is no valid SWO supporting the billed 
supplies. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) 
supplies rendered on April 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 6, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on April 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested inpatient hospital 
admission is medically necessary. The Plan denied your request. The Plan says the requested inpatient hospital 
admission does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the enrollee is medically stable and has undergone medical clearance for 
the procedure. There is no clinical rationale for inpatient level of care services after the procedure. The record 
did not show that at the time of inpatient admission the admitting physician reasonably expected that the 
enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 
 
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 acute inpatient hospital 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 need rehabilitation due to just having surgery. 
The Plan denied your request. The Plan says the denial of authorization for IRF care is correct. 
 
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 your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you may need physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy 
program. There is not a reasonable expectation that you 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that you are in pain and need the requested 
procedure. The Plan denied your request. The Plan says the records do not show that a team of doctors and a 
mental health expert has examined the enrollee and determined that he is a good candidate for the requested 
treatment. 
 
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 spinal cord stimulator. Our reviewer 
says that a spinal cord stimulator is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee did not have a psychological evaluation. Our physician reviewer found 
that a spinal cord stimulator is considered experimental and investigational for the treatment of low back pain 
and/or SI joint pain. 
 
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 spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic shoes and inserts provided on September 27, 
2021. 
 
You asked the Plan to pay for the diabetic shoes and inserts. You say that the unspecified code was reported in 
error. This has been corrected, and this claim should be paid. The Plan denied your request. The Plan says the 
use of the unspecified side diagnosis code when it is known a condition occurs on both sides is improper 
coding and was correctly denied. No corrected claim was submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill in accordance with ICD-10 
guidelines. The guidelines indicate that unspecified side diagnosis codes should be used when the laterality of 
the condition is not described in the records.  
We looked at the file and Medicare rules. This condition occurs on the left and right. As such, reporting the 
unspecified code for this claim is incorrect billing. Based on this information, we decided that Medicare rules 
for coverage of the diabetic shoes and inserts have not been met. Therefore, we decided that the Plan does not 
have to pay for the diabetic shoes and inserts provided on September 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional benefit allowance for progressive lenses. 
 
You asked the Plan to pre-approve an additional benefit allowance for progressive lenses. The Plan denied your 
request. The Plan says that the Plan offers a vision care benefit that covers up to three pairs of select 
eyeglasses, not to exceed $175 per pair, including upgrades. ($525 maximum benefit). The benefit states that 
youre responsible for paying all costs above the maximum amounts. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  We looked at the file and the Plan's rules. The file shows that the Plans vision benefit covers up to three pairs 
of select eyeglasses, not to exceed $175 per pair, including upgrades. ($525 maximum benefit). Therefore, we 
decided that the Plan does not have to pre-approve an additional benefit allowance for progressive lenses.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable control system. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request exceeds your needs. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 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 requested services. Our physician 
reviewer found that you have a medical history including Parkinson's Disease with recurrent falls who has been 
authorized to have a group 3 power wheelchair to assist with mobility. An expandable controller is an 
electronic system that is capable of accommodating one or more additional features and can operate 3 or more 
powered seating options. In this case, you have a neurologic disorder with functional deficits. Criteria for a 
power wheelchair are met. The requested electrical accessories are not medically necessary as you do have use 
of the upper extremities. You can operate and control the power options using the switches that are included in 
the basic wheelchair. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable control system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy (97039, 97139) and chiropractic services 
(97140, 98943) provided on August 18, 2021. 
 
You asked the Plan to pay for physical therapy and chiropractic services. You say that you were told by 
representatives of the Plan that the services at issue would be covered. The Plan denied your request. The Plan 
says rules for payment for chiropractic services have not been met. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue were not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for physical therapy (97039, 97139) and chiropractic services (97140, 98943) 
provided on August 18, 2021.  
 Your complaint about receiving erroneous or incomplete information about your benefits from representatives 
of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction and visit you had on February 22, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim processed 
correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a refraction when provided as part of a routine eye exam. 
 
We looked at the file and the Plan's rules. The records do not show that the refraction was provided as part of a 
routine eye exam. Based on this information, we decided that the Plan's rules for coverage of the services have 
not been met. Additionally, the Medicare covered vision services you received require a $30 copayment 
responsibility. This means that you have been asked to pay the correct amount based on your contract with the 
Plan. Therefore, we decided that the Plan does not have to pay for the eye refraction and visit you had on 
February 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 11, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
genetic testing provided on November 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humalog (J1815). 
 
You asked the Plan to pre-approve Humalog. You say that the enrollee is in need of the specific brands given 
she has had reported allergies to other brands. The Plan denied your request. The Plan says the requested 
insulin will be self-injected and is not covered under the medical 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 Humalog (J1815).  
 Benefits for Humalog 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks. 
 
You asked the Plan to pre-approve medial branch blocks. You say that the requested medial branch blocks are 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested medial branch blocks. 
 
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 medial branch blocks. Our reviewer 
says that the enrollee does not meet criteria for the requested medial branch blocks. Our physician reviewer 
found the medical records submitted did not include the percentage of pain relief experienced from the 
previous medial branch blocks the enrollee received on March 9, 2022. The review has determined that the 
enrollee does not meet the above LCD criteria for the requested medial branch blocks. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of medial branch blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve medial branch blocks.