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

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair (K0823) and accessories 
(E0973x2, E2365x2, E1028). 
 
 
 
 You asked the Plan to pre-approve a power wheelchair and accessories. You say that the power wheelchair is 
medically necessary. The Plan denied your request. The Plan says the requested wheelchair and accessories are 
not deemed medically necessary. There is no documentation to support you are unable to perform ADLs and 
iADLs within your home. You are independent and functional in your ADL and iADL with assist device of lift 
chair and 4-wheel walker. 
 
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 power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found based on the medical records provided, there is documentation that you 
have a personal mobility deficit that impairs participation in mobility related activities of daily living such as 
toileting, feeding, grooming, and bathing in customary locations within the home. Conflicting reports are 
provided in this case as to whether your mobility deficit can be helped by the use of a walker, cane or manual 
wheelchair. A medical evaluation on January 4, 2023, indicated that your mobility deficit could not be helped 
by the use of a walker, cane or manual wheelchair. A physical therapy evaluation in your home on February 20, 
2023, indicated you were a limited functional ambulator in the home who would benefit from a rolling walker 
with a seat. At that time, you were walking 50 feet with no assistive device; reportedly you indicated the power 
wheelchair was to be primarily for use in the community. The records do not clearly show that you meet all of 
the LCD criteria for approval of the power wheelchair and accessories. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 2 power wheelchair (K0823) and accessories (E0973x2, 
E2365x2, E1028).
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 LTACH is the appropriate level of 
care for this enrollee. You say the enrollee is medically stable to be transferred to the LTACH level of care at 
this time. The Plan denied your request. The Plan says the enrollee does not meet the Medicare guidelines for 
care in an LTACH. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ultomiris (J1303). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says this drug is not found to be reasonable and necessary based on review 
of compendia. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 pre-approve the medication. Our physician reviewer 
found the record indicates that the enrollee has a diagnosis of Myasthenia gravis, anti-achetylcholine receptor 
(AChR) antibodies status unknown. The FDA has not stated that the requested drug is indicated for the 
enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of 
the requested drug in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied. 
The requested service cannot be recommended. 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 medication have not been 
met. Therefore, we decided that the Plan does not have to pre-approve Ultomiris (J1303).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) (64483). 
 
You asked the Plan to pre-approve a repeat ESI. You say that the enrollee has tried and failed physical therapy. 
You say that the enrollee had a previous injection with success. You also say that the requested ESI would help 
to improve the enrollee's function, pain and quality of life. The Plan denied your request. The Plan says the 
requested repeat ESI is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI may be considered medically reasonable 
and necessary when the medical record documents that the first injection provided at least 50% of sustained 
improvement in pain relief for three months. 
 
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 repeat ESI. Our reviewer says that a 
repeat ESI is not medically necessary. Our physician reviewer found the provided documentation does not 
support that the enrollee had 50% pain relief for three months. Therefore, the reviewer found that a repeat ESI 
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 repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI) (64483).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88305) provided on October 3, 2022. 
 
You asked the Plan to pay for pathology services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says the diagnosis codes reported on this claim cannot be reported together. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that diagnosis codes with an Excludes1 note cannot be reported together.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of pathology services have not been met. Specifically, the diagnosis codes reported on this claim 
include D12.2, D12.3, and K63.5. However, codes within the D12 code set have an Excludes1 note stating that 
these codes cannot be reported with code K63.5. Therefore, we decided that the Plan does not have to pay for 
pathology services (88305) provided on October 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SelectMDx genetic testing provided on October 11, 2022. 
 
You asked the Plan to pay for SelectMDx genetic testing. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  
The Plan must follow Medicare rules. Medicare rules say that NGS as a diagnostic laboratory test is reasonable 
and necessary and covered nationally when the criteria listed in the Medicare rules section of this letter have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SelectMDx genetic testing have not been met. Specifically, we determined that SelectMDx genetic 
testing does not have FDA clearance. Therefore, we decided that the Plan does not have to pay for SelectMDx 
genetic testing provided on October 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the seat lift mechanism, electric (E0627) and lift chair 
(E1399). 
 
You asked the Plan to pre-approve the seat lift. You say that you are concerned that you will fall over when 
you get up out of your chair. The Plan denied your request. The Plan says the seat lift mechanism is not 
medically necessary, and the lift chair is considered equipment that serves comfort and convenience. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
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 seat lift. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found the requested lift chair (E1399) is statutorily non-covered as it serves no primary medical 
purpose.  A letter of medical necessity reports the need for the seat lift, though the supplied medical visit notes do not provide any details indicating the device as part of the treating practitioner's course of treatment or that 
the device will affect improvement in the patient's condition, or arrest or retard deterioration in the enrollees 
condition. The provided records indicate the enrollee is supervision level for sit to stand transfers and the 
records show that the enrollee has the ability to ambulate. 
 
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 seat lift have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the seat lift mechanism, electric (E0627) and lift chair (E1399).
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 0018U. We decided that 
the Plan does not have to pay for the services described by procedure code(s) 0245U.  
 
You asked the Plan to pay for laboratory services (0018U and 0245U) provided on August 9, 2022. You say 
that these services were necessary and are supported in the medical record. The Plan says that the payment for 
code 0245U is included in the payment for code 0018U. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 0018U.  
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 0018U.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
0245U. 
 
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 0245U 
is a column II code to column I code 0018U. 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 the services described by procedure code(s) 0245U. 
 
 
 
 
 
 
 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that there is documentation of tried and failed 
treatments. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in 
VAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD and HFrEF 
and was recently hospitalized with a COPD exacerbation. Arterial blood gas was consistent with acute on 
chronic hypercarbic respiratory failure. There is no ABG done while stable to confirm chronic CO2 retention. 
If the enrollee does have chronic CO2 retention, she may benefit from BiPAP with AVAPS during sleep. 
Medicare does not cover a home ventilator when he used at settings that can be provided with 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from March 24, 2022, to 
March 29, 2022. 
 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 a DRG review was performed which resulted 
in a change in DRG from 871 to 638. 
 
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 . 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 the 
enrollee presented with vomiting and hyperglycemia.  She was diagnosed with and treated for diabetic 
ketoacidosis (DKA). The enrollee was also treated for possible pneumonia, though no definitive evidence of 
any source of infection was identified.  The enrollees presentation, vital signs and laboratory findings can all 
be explained by a diagnosis of DKA. There is no evidence that the enrollee had a second, separate diagnosis of 
sepsis. As such, the billing of A41.9 and J15.6 is not supported.  
 
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 March 24, 2022, to March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-share for myocardial perfusion imaging, a stress test, 
and an injection provided on August 10, 2022. 
 
You asked the Plan to waive the cost-share for myocardial perfusion imaging, a stress test, and an injection. 
You say that you dont understand why you have this cost-share. 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 $100 
copayment for in-network outpatient diagnostic radiology services, a $10 copayment for diagnostic tests other 
than x-rays, laboratory tests, mammograms, and radiology, and a 20% coinsurance for Medicare Part B drugs. 
 
You have been asked to pay a $100 copayment for myocardial perfusion imaging. You have also been asked to 
pay $10 copayment for a stress test. These items/services fall within the outpatient diagnostic radiology 
services benefit category.  You have also been asked to pay a $453.13 coinsurance for an injection ($2,265 
allowed amount x 20% coinsurance = $453.13 applied coinsurance). This item/services falls within the 
Medicare Part B drugs benefit category. You have been asked to pay a total of $563.13 cost-share for 
diagnostic testing and injections ($10 copayment + $100 copayment + $453.13 coinsurance= $563.13).  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 cost-share for myocardial perfusion imaging, a stress test, and an injection 
provided on August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee suffers from chronic respiratory 
failure due to obesity hypoventilation syndrome. Without NIV therapy, the enrollee is at high risk for hospital 
readmissions and potentially life-threatening exacerbations or death. The Plan denied your request. The Plan 
says records do not show failure of BiPAP. The records show that CPAP helped the enrollee in the hospital. 
The nurse practitioner has requested a NIV in AVAPS mode, which can be met by a BiPAP. The request is not 
medically necessary. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD, severe 
obesity, and obesity hypoventilation syndrome. During a recent hospitalization, arterial blood gases were 
consistent with acute on chronic hypercarbic respiratory failure.  There are no ABGs done while stable to 
document chronic CO2 retention. If this enrollee does have chronic CO2 retention, she may benefit from 
BiPAP with AVAPS during sleep. Medicare does not cover a home ventilator when used at settings that can be 
provided with 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 64479 and 64480 billed for June 27, 2022. 
 
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 that the services are not payable as billed. 
 
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. The Plan states that codes 64479 and 64480 have a PC/TC indicator of 0 and are 
not payable when billed to hospital inpatients or patients in a hospital outpatient department. While the codes 
have a PC/TC indicator of 0, the file shows that the services were billed with Place of Service (POS) code 11 
for an office. The Plan has provided no documentation to show that the services were performed to a hospital 
inpatient or outpatient. Therefore, we decided that the Plan has to pay for procedure codes 64479 and 64480 
billed for June 27, 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.