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

 
We decided that the Plan has to pay for the electrical stimulator supplies provided on September 9, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that the proof of 
delivery did not include an order number or details to corroborate the delivery ticket submitted, and the proof 
of delivery is not itemized to indicate the specific supplies. 
 
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 argues that the proof of delivery did not include an order number or 
details to corroborate the delivery ticket submitted, and the proof of delivery is not itemized to indicate the 
specific supplies. However, the records contain an itemized packing slip dated September 9, 2022, with the 
same tracking number as the delivery ticket dated September 14, 2022. As such, the records support that the 
items at issue in this case were delivered. Therefore, we decided that the Plan has to pay for the electrical 
stimulator supplies provided on September 9, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs rehabilitation to gain strength 
back in legs to be able to walk again without any assistance. The Plan denied your request. The Plan says the 
enrollee's records show that it is not reasonable to expect that you will be able to safely participate in, or fully 
benefit from, the intensity of services of an IRF, and can safely receive the services needed in other settings, a 
skilled nursing facility or home with home health services. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, and medical needs do not require an acute 
hospital inpatient rehab stay with an interdisciplinary approach to rehabilitative 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve adjustable arm rests, expandable controller, electrical 
harness, and electronic connector. 
 
You asked the Plan to pre-approve adjustable arm rests, expandable controller, electrical harness, and 
electronic connector. 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 follows Medicare rules. Medicare rules say that power wheelchair accessories are covered when 
specific criteria 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 adjustable arm rests, expandable 
controller, electrical harness, and electronic connector. Our reviewer says that the services are not medically 
necessary. Our physician reviewer found the requested electrical accessories are not medically necessary as the 
enrollee does have use of the upper extremity and 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 adjustable arm rests, expandable controller, electrical harness, and electronic 
connector have not been met. Therefore, we decided that the Plan does not have to pre-approve adjustable arm 
rests, expandable controller, electrical harness, and electronic connector.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided on 
September 7, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says the documentation 
submitted did not include an itemized bill or proof of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The documentation 
does not contain an itemized packing slip or delivery ticket for the items in question. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that 
the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided on September 7, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full cost for an extraction, erupted tooth or exposed root 
(D7140), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation 
of mucoperiosteal flap if indicated (D7210), and deep sedation/general anesthesia  first 15 minutes (D9222) 
provided on August 18, 2022, and October 21, 2022. 
 
You asked the Plan to pay the full cost for the dental services. You say that you are requesting $327 be sent to 
the enrollee. The Plan denied your request. The Plan says the enrollees benefit for the requested services 
$1,500 dollar limit was met. 
 
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, certain limitations apply. The records 
show that the Plan made the following payments, April 4, 2022 $327, August 18, 2022 $100, and August 18 
and October 21, 2022 $1,073 ($327 + $100 + $1,073 = $1,500). Therefore, we decided that the Plan does not 
have to pay the full cost for an extraction, erupted tooth or exposed root (D7140), extraction, erupted tooth 
requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated 
(D7210), and deep sedation/general anesthesia  first 15 minutes (D9222) provided on August 18, 2022, and 
October 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies (A4595) provided on September 5, 
2022. 
 You asked the Plan to pay for the electrical stimulator supplies. You say that this claim was billed correctly. 
The Plan denied your request. The Plan says that the documentation does not include a proof of delivery or a 
delivery ticket. 
 
The Plan must follow Medicare rules. Medicare rules say that DMEPOS is covered only when there are both a 
physician order and proof of delivery. 
 
We looked at the file and Medicare rules. The record does contain a valid proof of delivery. The electrical 
stimulator supplies are supported by the records provided because the packing slip and the third-party delivery 
tracking information have a tracking number to link those documents together. The documents meet the 
Medicare rules for valid proof of delivery. Based on this information, we decided that Medicare rules for 
coverage of the electrical stimulator supplies have been met. Therefore, we decided that the Plan has to pay for 
the electrical stimulator supplies (A4595) provided on September 5, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Novabone macroform allograft (20930). 
 
You asked the Plan to pre-approve the allograft. You say that the allograft is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the Novabone Macroform Allograft 
in the setting of anterior cervical spine fusion surgery have not been demonstrated in the peer-reviewed 
literature. 
 
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 allograft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient reliable evidence in the form of high-quality peer-reviewed medical 
literature to establish the safety and efficacy of the requested product for use in cervical fusion procedures. 
The 'gold standard' for cervical spine fusions appears to remain autograft, at this time. Exceptional indications were 
not evident in the provided records. Therefore, the requested Novabone Macroform allograft, in this case, is not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the allograft have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Novabone macroform allograft (20930).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99204, 99214) with a neurosurgeon to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits. You say that you are in a lot of pain in your cervical and your 
neck and you need a neurosurgeon to evaluate you as soon as possible. The Plan denied your request. The Plan 
says you have a network primary care physician (PCP) who is responsible for providing your routine health 
care needs and overseeing your care. If you need certain types of covered services or supplies from network 
providers, you must get approval in advance from your PCP (such as giving you a referral). 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits (99204, 99214) with a neurosurgeon to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service May 17, 
2022. 
 
You asked the Plan to pay for procedure code S9328. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service May 17, 2022.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve E0978, E2311, E2313, E2377. We decided that the Plan does not 
have to pre-approve E2300, K0108.  
 
You asked the Plan to pre-approve additional power wheelchair accessories (E0978, E2300, E2311, E2313, 
E2377, K0108).. You say that this is medically necessary. The Plan says that these accessories cannot be 
approved. 
 
We decided that the Plan has to pre-approve E0978, E2311, E2313, E2377.  
 
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 for these accessories. Our reviewer says that the 
enrollee has a spinal cord injury and a history of stroke. The enrollee has very limited bilateral upper extremity 
strength, with the left worse than right. The physician has noted that the enrollee requires multiple toggle 
switches to handle the multiple power drives on the 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 accessories have been met. Therefore, we decided that the Plan has to pre-
approve E0978, E2311, E2313, E2377.  
 
We also decided that the Plan does not have to pre-approve E2300, K0108.  
The Plan must follow Medicare rules. Medicare rules say that services are not covered if they are not primarily 
medical in nature. 
 
E2300 is statutorily not covered by Medicare, as it is not primarily medical in nature. Additionally, the lateral 
positing wedge, pair represented by K0108 is also not medical in nature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of E2300, K0108 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve E2300, K0108. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy home health services provided on dates of 
service from June 14, 2022, to July 8, 2022. 
 
You asked the Plan to pay for physical therapy. You say that the services at issue have been billed correctly. 
The Plan denied your request. The Plan says the combination of therapy code and revenue code on the claim is 
invalid. 
 
The Plan must follow Medicare rules. Medicare rules say that the appropriate physical therapy revenue code for 
G0151 is 042x. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy have not been met. Specifically, the case record reflects that a claim line for 
physical therapy code G0151 was billed with an invalid revenue code indicating skilled-nursing services. Code 
G0151 does not refer to skilled-nursing services. The use of a skilled-nursing revenue code in combination with 
code G0151 is not appropriate.  
  Therefore, we decided that the Plan does not have to pay for physical therapy home health services provided on 
dates of service from June 14, 2022, to July 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SiPortfolio testing (81455, G0452) provided on August 31, 
2022. 
 
You asked the Plan to pay for SiPortfolio testing. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this test was 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 pay for SiPortfolio testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has no personal history of cancer. The review has determined that the 
items/services at issue in this case are 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 SiPortfolio testing have not been met. Therefore, we decided that the Plan does 
not have to pay for SiPortfolio testing (81455, G0452) provided on August 31, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from July 12, 
2022, to August 10, 2022. 
 
You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says the enrollee no longer had 
skilled nursing facility needs. 
 
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 pay for 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 that the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
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 pay for skilled nursing facility (SNF) care provided from July 12, 2022, to August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life2000 home ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records do not show a trial of bilevel positive airway pressure (BiPap) or 
continuous positive airway pressure (CPAP) 
devices. 
 
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 the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that this device 
is not a true ventilator, because it is not capable of providing full ventilatory support. Its primary intended use 
is during activity, and not to treat chronic carbon dioxide (CO2) retention during sleep. There is inadequate evidence of its safety and effectiveness in the treatment of COPD. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Life2000 home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent observation care (code 99226) provided from 
May 8, 2022, to May 10, 2022. 
 
You asked the Plan to pay for subsequent observation care. The Plan denied your request. The Plan says we 
have insufficient documentation to corroborate the services so we can confirm Medicare coverage has been 
met. 
 
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 subsequent observation care have been 
met. Therefore, we decided that the Plan does not have to pay for subsequent observation care (code 99226) 
provided from May 8, 2022, to May 10, 2022.