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

 
We decided that the Plan has to pre-approve ultra-light weight wheelchair and accessories (CPT code(s): 
K0005, E2203 x2, E2211 x2, E0961 x2, E0990 x2, E0973 x2, E0971 x2, E0978, E2617, and E2609). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says that the notes say the enrollee has Alzheimer's, they tend to slide out of their current 
wheelchair, the Ultra-Light Weight Wheelchair with accessories is not approved and they do not meet the 
enrollee's current needs. 
 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 DME. Our physician reviewer 
found based on the medical records provided there is documentation that meet the requirements listed in the 
LCD: Manual Wheelchair Bases (L33788) and the LCD: Wheelchair Seating (L33312) for Medicare coverage 
for the ultralightweight wheelchair and multiple accessories as detailed above. The enrollee is non-ambulatory 
and does not have a manual wheelchair of the enrollee's own (the enrollee is using a wheelchair borrowed from 
the facility in which the enrollee resides). There is documentation that this enrollee has 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 and there is documentation that the enrollee's 
mobility deficit cannot be helped by the use of a walker or cane and the enrollee has not expressed an 
unwillingness to use the wheelchair and the enrollee's home has adequate spaces and surfaces for safe use of 
the wheelchair. Records document the need for individualized adjustments, non-standard seat frame depth, 
adjustable height, custom seating and cushioning due to the enrollee's posture. Pneumatic propulsion tires are 
required for self-propulsion. Elevating leg rests are required due to documented edema. Brake extensions are 
needed due to decreased upper extremity range of motion. Anti-tippers are needed due to fall/tipping risk. 
Seatbelt is required for hip positioning. 
 
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 DME have been met. Therefore, we decided that the Plan has to pre-approve 
ultra-light weight wheelchair and accessories (CPT code(s): K0005, E2203 x2, E2211 x2, E0961 x2, E0990 x2, 
E0973 x2, E0971 x2, E0978, E2617, and E2609).  
 
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 the power operated vehicle (three or four wheel 
nonhighway) specify brand name and model number (CPT code E1230). 
 
You asked the Plan to pre-approve the power operated vehicle. You say that the power operated vehicle is 
necessary. The Plan denied your request. The Plan says the clinical records do not support a health need for this 
request. The Plan states an in-home independent durable medical equipment (DME) evaluation is approved to 
determine the health need for a Power Scooter or other safe medical equipment to help you move. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 
 
 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 power operated vehicle. Our 
physician reviewer found 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. There is no documentation that your mobility deficit cannot be helped by 
the use of a walker or manual wheelchair. Records dated April 04, 2022, indicate you are currently using a 
walker and manual wheelchair. There is no documentation that you can safely operate a power mobility device. 
 
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 power operated vehicle have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the power operated vehicle (three or four wheel nonhighway) specify brand 
name and model number (CPT code E1230).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology consultation during surgery (88329) provided 
on December 9, 2021. 
 
You asked the Plan to pay for the pathology consultation. You say that this code was billed correctly, and no 
errors were found in your system. The Plan denied your request. The Plan says this service cannot be billed 
with modifier 26 or TC. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that modifiers 26 and TC cannot be billed with services with a PC/TC indicator of 0. 
 We find that CPT code 88329 was not billed according to Medicare guidelines. Specifically, this service was 
billed with modifier 26, but CPT code 88329 has a PT/TC indicator of 0. Based on this information, we 
decided that Medicare rules for coverage of the pathology consultation have not been met. Therefore, we 
decided that the Plan does not have to pay for the pathology consultation during surgery (88329) provided on 
December 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One injections (J7326). 
 
You asked the Plan to pre-approve the Gel-One injections. You say that the injections are medically necessary. 
The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations is covered when the patient has failed at least three months of 
conservative therapy. 
 
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 Gel-One injections. Our reviewer 
says that the injections are not medically necessary. Our physician reviewer found there is no documentation 
that this patient has failed to respond adequately to at least a three-month trial of simple analgesic therapy (such 
as acetaminophen or ibuprofen) and conservative non-pharmacologic therapy (such as home exercise or 
physical therapy). 
 
 
 
 
 
 
 
  
 
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 Gel-One injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Gel-One injections (J7326).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on February 2, 2022. 
 
You asked the Plan to pay for the core buildup. The Plan denied your request. The Plan says this service is not 
covered. 
 
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 pay for the core 
buildup, including any pins when required (D2950) provided on February 2, 2022.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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 do not require an 
acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitation care. Documentation does not support the medial necessity for admission to an IRF. While you may benefit from physical and 
occupational therapy, your rehab needs can be addressed at a low intensity alternate setting such as in a skilled 
nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care from April 13, 2022, through April 19, 2022. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there is no documentation that daily skilled 
services are required. The patient is walking household distances with a rolling walker with stand-by assistance 
and was stand-by assist for transfers. Provided records do not document a significant decline in the patients 
functional status to necessitate daily inpatient skilled therapy services. Based on the medical records provided 
there is no documentation that the patient requires the services on an inpatient basis, only in a SNF setting. 
Records do not document the services in the home with home health care or in a long-term care facility on a 
part time basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care from April 13, 2022, through April 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional doses of Feraheme (Q0138). 
 
You asked the Plan to pre-approve the additional doses of Feraheme. You say that these injections are 
medically necessary. The Plan denied your request. The Plan says 6 of the 10 requested doses have been 
approved. Additional doses are not medically necessary. 
 
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 additional doses of Feraheme. Our 
reviewer says that the additional injections are not medically necessary. Our physician reviewer found the 
recommended dose of Feraheme is an initial 510 mg dose followed by a second 510 mg dose 3 to 8 days 
later. The additional requested doses are not medically 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 additional doses of Feraheme have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 4 additional doses of Feraheme (Q0138).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on August 30, 2021. 
 
You asked the Plan to pay for foot orthotics. You say that  The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
 
 
 
 
 
 
 
 
 Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on August 30, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic imaging (D0330) provided by an 
out-of-network provider February 28, 2022. 
 
You asked the Plan to pay for panoramic radiographic imaging. You say that you have a terrible gag-flex. You 
say that is why they had to do panoramic imaging. The Plan denied your request. The Plan says D0330 has 
been correctly denied. 
 
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 pay for 
panoramic radiographic imaging (D0330) provided by an out-of-network provider on February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subarachnoid injection (62320), provided on November 25, 
2022. 
 
You asked the Plan to pay for a subarachnoid injection. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this service is considered experimental. 
 
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 a subarachnoid injection. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case.  
 Our physician reviewer found the provided documentation does not contain sufficient information in the 
medical records submitted. In addition, the records submitted were not dated and not signed. 
 
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 subarachnoid injection have not been met. Therefore, we decided that the Plan 
does not have to pay for a subarachnoid injection (62320), provided on November 25, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray provided on July 8, 2021. 
 
You asked the Plan to pay for the x-ray. You say that this service was not bundled with other procedure codes 
performed on the same date of service. The Plan denied your request. The Plan says the enrollees claim would 
be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the chest x-ray provided on July 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the seat lift mechanism (CPT code E0627) and chair 
(CPT code E1399). 
 
You asked the Plan to pre-approve the DME. You say that you need the recliner chair. The Plan denied your 
request. The Plan says the requirements are not met due to no documentation that you are unable to stand from 
any chair, or that you have a severe neuromuscular disease or condition. 
 
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 DME. Our physician reviewer 
found there is documentation of arthritis of the hip, pelvis and lumbar spine. The medical office notes do not 
mention the seat lift in the treating practitioner's course of treatment. A pre-printed form that appears to be 
supplied by the device vendor and signed by the practitioner indicates the seat lift is included in the treating 
practitioner's course of treatment. The medical office notes do not specifically indicate the seat lift will likely effect improvement in your condition or arrest or retard deterioration in the patient's condition. A pre-printed 
form that appears to be supplied by the device vendor and signed by the practitioner indicates the seat lift will 
likely effect improvement in your condition or arrest or retard deterioration in your condition. There is no 
documentation that you are completely incapable of standing from a chair in the home; the supplied certificate 
of medical necessity indicates the opposite. There is documentation that you have 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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the seat lift mechanism (CPT code E0627) and chair (CPT code E1399).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you are medically stable with no acute problems and have no medical complexity and 
do not need PM&R physician close supervision 3 times per week (at a minimum) for the ongoing management 
of any active or acute exacerbations of chronic medical conditions. At the current functional status, you do not 
need 3 hours a day five days a week of IRF therapies with interdisciplinary management. While you may 
benefit from physical therapy, and occupational therapy, your rehab needs can be addressed at a low intensity 
alternate setting such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane injections (J7318). 
 
You asked the Plan to pre-approve Durolane injections. The Plan denied your request. The Plan says there is no 
documentation that the enrollee has tried Monovisc, Orthovisc, or Synvisc/Synvisc-One, or has a reason or 
reasons why an exception should be made to the step therapy requirements. 
 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 Durolane injections. Our reviewer says 
that Durolane injections are not medically reasonable and necessary for the enrollee. Our physician reviewer 
found the Plan requires a trial of Monovisc, Orthovisc or Synvisc/Synvisc-One before they will approve the 
requested drug. Our reviewer found that there is no indication that the patient has tried and failed the required 
drug(s), Monovisc, Orthovisc, or Synvisc/Synvisc-One. Our physician reviewer also found that there is no 
indication that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for 
the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Durolane injections (J7318).