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

 
We decided that the Plan does not have to pre-approve intermediate proton delivery treatment (77523). 
 
You asked the Plan to pre-approve intermediate proton delivery treatment. You say that this service is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the records do not show why 
proton treatment is being considered rather than other radiation treatment options, or whether treatment options 
were discussed with the enrollee. 
 
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 intermediate proton delivery treatment. 
Our reviewer says that the requested intermediate proton delivery treatment is not considered medically 
reasonable and necessary in this case. Our physician reviewer found nothing in the case file suggests that 
standard dosimetric constraints cannot be met with a non-proton-based treatment, and it is not plausible that 
proton therapy would be needed to meet these constraints. Proton therapy will almost always reduce dose to 
surrounding normal tissues. Our reviewer also found that simply demonstrating that proton therapy will reduce 
the low dose to normal tissues does not necessarily demonstrate that it is clinically needed relative to intensity-
modulated radiation therapy (IMRT) though, as the reductions should be clinically meaningful, and reduce 
toxicity risks in a clinically meaningful manner. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intermediate proton delivery treatment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve intermediate proton delivery treatment (77523).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair, loop heal, and detachable 
armrest to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a lightweight wheelchair, loop heal, and detachable armrest. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested items can be 
provided by a network provider. 
 
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 
a lightweight wheelchair, loop heal, and detachable armrest to be provided by an out-of-network (OON) 
provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neupro. 
 
You asked the Plan to pre-approve Neupro. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Neupro.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (E1230). 
 
You asked the Plan to pre-approve a power scooter. You say that the requested item is a medical necessity for 
you. The Plan denied your request. The Plan says rules for coverage for PMDs have not been met. 
 
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.  
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power scooter (E1230).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1, BRCA2 (breast cancer 1 and 2) gene analysis. 
 
You asked the Plan to pre-approve BRCA1, BRCA2 gene analysis. 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 BRCA 1 and BRCA 2 testing is 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 BRCA1, BRCA2 gene analysis. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the documentation 
indicates that the enrollee does not have breast cancer or a relative that has a cancer in the digestive gland 
called pancreas, cancer of breast or female organs (fallopian tube, ovary) or cancer of the prostate. The review 
has determined that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of BRCA1, BRCA2 gene analysis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve BRCA1, BRCA2 (breast cancer 1 and 2) gene analysis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skin substitute (Q4210 Axolotl Graft or Axolotl 
DualGraft, per sq cm). 
 
You asked the Plan to pre-approve skin substitute. 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 Medicare covers application of skin substitutes to 
Ulcers or Wounds when specific requirements 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 skin substitute. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found in this case, the record indicates that the 
enrollee has a traumatic lateral malleolar ulcer that has been present for a month with gradual improvement. 
The record does not document management of diabetes. The record provided does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the 
coverage criteria are not satisfied. The requested service is not 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 skin substitute have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skin substitute (Q4210 Axolotl Graft or Axolotl DualGraft, per sq cm).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the collagen purchased on September 4, 2022. 
 
You asked the Plan to pay for the collagen. The Plan denied your request. The Plan says collagen is not a 
covered expense, and is not reimbursable. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. However, your 
plan offers a supplemental benefit for specific OTC items. Collagen is not listed as a covered OTC benefit 
under the supplemental reimbursement program. Therefore, we decided that the Plan does not have to pay for 
the collagen purchased on September 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve padded bed rails 
 
You asked the Plan to pre-approve padded bed rails. You say that the padded bed rails serve as aids in 
supporting the enrollee's weak body parts caused by strokes. Without the padded rails, the medical bed 
becomes a safety issue for the enrollee. The Plan denied your request. The Plan says the side rails are being 
requested for safety and convenience and does not meet the coverage criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve padded bed rails
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex walk system (L5981). 
 
You asked the Plan to pre-approve a flex walk system. 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 a microprocessor controlled ankle foot system 
(L5973), energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system 
(L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) is 
covered for beneficiaries whose functional level is 3 or above. 
 
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 flex walk system. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the requested L5981 flex walk 
system exceeds the enrollee's medical needs per LCD L33787 and per Social Security Act, Section 1862 
(a)1(A) and the 42 CFR 411.15(k), as Medicare does not pay for any items or services that are not reasonable 
and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed 
body member. The documentation does not support that the enrollee is a K3 ambulator as the documentation 
notes that he would like a scooter for longer distances. 
 
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 flex walk system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a flex walk system (L5981).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro arm brace. 
 
You asked the Plan to pre-approve the MyoPro brace. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MyoPro brace. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the MyoPro is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in 
widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this enrollee, improve hemiparetic arm function, or be safe 
for long-term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 MyoPro brace have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the MyoPro arm brace.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lab services provided on July 29, 2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that you get this test every year and 
have never had to pay before. 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 $5 
copayment for diagnostic lab services. 
 
You have been asked to pay a $5 copayment for the lab services. This item/service falls within the diagnostic 
lab services benefit category. 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 copayment for the lab services provided 
on July 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a special power wheelchair (group 3) with features 
(K0849, E2208, (E2361, A9900, E1028, E0973). 
 
You asked the Plan to pre-approve a special power wheelchair with features. You say that the requested 
wheelchair is medically necessary and appropriate to meet the enrollee's positioning needs. The Plan denied 
your request. The Plan says per Medicare rules, the requested wheelchair is medically necessary when the 
enrollee has certain conditions causing problems with walking. Notes do not show that the enrollee has no 
diagnosis causing mobility limitation to meet the requested wheelchairs criteria, including no documentation of 
neurologic disorder, myopathy or congenital skeletal diagnosis causing mobility limitation. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
special power wheelchair (group 3) with features (K0849, E2208, (E2361, A9900, E1028, E0973).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapies provided on May 16, 
2022, to May 23, 2022. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you are disputing the share cost. 
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 $35 
copayment for outpatient rehabilitation services. There were two visits, resulting in a total copayment amount 
of $70. 
 
You have been asked to pay $35 copayment for each physical therapy. This item/service falls within the 
outpatient rehabilitation services benefit category. 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 copayment for 
physical therapies provided on May 16, 2022, to May 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDX testing (0037U) provided on June 
29, 2022. 
 
You asked the Plan to pay for the FoundationOne CDX testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange.  
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the FoundationOne 
CDX testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
FoundationOne CDX testing (0037U) provided on June 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided on July 21, 2022, to July 26, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for hospital services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says services provided out-of-network without prior authorization are not 
covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for hospital services provided on July 21, 2022, to 
July 26, 2022, by an out-of-network (OON) provider.
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 IRF care to progress and get 
better. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services 
do not meet the requirements for approval. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for orthopedic surgery provided on June 15, 
2022. 
 
You asked the Plan to waive the coinsurance for orthopedic surgery. You say that you are disputing the share 
cost. 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 50% 
coinsurance for outpatient hospital services. The allowed amount of this orthopedic surgery total $5,857.68, 
resulting in a coinsurance amount of $2,928.83. 
 
You have been asked to pay 50% coinsurance for orthopedic surgery. This item/service falls within the 
outpatient hospital services benefit category. 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 coinsurance for orthopedic 
surgery provided on June 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on June 1, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the radiology services. You say that the referring provider ordered the tests and 
you would like an approval for the services rendered. The Plan denied your request. The Plan says the 
rendering and referring providers are both OON providers and there was no approved authorization. Also, the 
service rendered was not urgent or emergent. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the radiology services provided on June 1, 2022, 
by an out-of-network (OON) provider.