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

 
We decided that the Plan has to pre-approve the vertical shock-reducing pylon. We decided that the Plan does 
not have to pre-approve the vacuum-assisted socket system.  
 
You asked the Plan to pre-approve a vacuum-assisted socket system and a vertical shock-reducing pylon.. You 
say that this is medically necessary. The Plan says that the vacuum assisted socket system and vertical shock 
reducing pylon were requested but does not meet Medicare criteria as reasonable and necessary.  
We decided that the Plan has to pre-approve the vertical shock-reducing pylon.  
 
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 the vertical shock-reducing pylon. Our reviewer 
says that the plan is incorrect in stating the enrollee's functional practice does not warrant this system. The 
enrollee has been using such a system for some time now. Medical necessity criteria are met as the plan has not 
provided sufficient evidence for denying a system she has relied upon. 
 
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 items have been met. Therefore, we decided that the Plan has to pre-approve 
the vertical shock-reducing pylon.  
 
We also decided that the Plan does not have to pre-approve the vacuum-assisted socket system. 
 
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 the vacuum-assisted socket system. Our reviewer 
says that this does not have support as a medically necessary system. The evidence-based support is weak as 
does not indicate the system significantly impacts function or prevents wound breakdown, based on an 
independent review of the literature. The medical standards of practice are not met. 
 
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 vacuum-assisted socket system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the vacuum-assisted socket system. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (procedure code 97110) provided 
to the enrollee on June 10, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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, the CPT Code Manual definition of code 97110 is "Therapeutic procedure, 1 or more areas, each 
15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical record includes 
evidence that a physical therapy assistant (PTA) performed therapy in the home due to the patient's homebound 
status. In this case, the services billed could have had a more appropriate Healthcare Common Procedure 
Coding System (HCPCS)  to report for service provided in the home.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for physical therapy services (procedure code 97110) provided to the enrollee on June 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 15, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare says screening services with no relation to a medical diagnosis of disease for the health 
of the patient are not a benefit. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the review indicates that the enrollee's diagnosis is encounter for general adult medical examination 
without abnormal findings. These services would therefore not be 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on April 15, 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 IRF care is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says rules for IRF care have 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 that, at the current functional level, the enrollee does not need 3 hours a day, 5 days a 
week, of therapies with multidisciplinary approach in an IRF. The available documents do not support the medical necessity due to lack of medical complexity and nursing needs for an admission to 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF 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 IRF 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 the enrollee has had a functional decline from their baseline level of function, but it is 
unlikely that they can participate in and benefit from the intensity of therapies provided on acute inpatient 
rehabilitation. 
 
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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have documented skilled nursing needs. The enrollee does 
not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. 
 
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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87801, 87481, 87640, 87653, 87651, 
87798) provided on April 26, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the enrollee has elongated toenails that are 
discolored and have subungual debris. Toenails are clinically significant for onychomycosis. Toenail 
specimens were taken and sent to the lab for evaluation. The Plan denied your request. The Plan says the 
request does not meet Medicare rules as reasonable and necessary. A review of the medical literature and 
clinical practice guidelines do not support PCR testing as a first line approach for evaluation of nail disorders 
and it is not widely accepted as standard of care. The requested testing exceeds the enrollee's medical needs. 
 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 laboratory services. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found 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 
determination of medical necessity must be tailored to the individual enrollee and their unique clinical scenario. 
The review of the medical literature and clinical practice guidelines do not support PCR testing as a first line 
approach for evaluation of nail disorders and it is not widely accepted as standard of care. The requested testing 
exceeds the enrollee's medical needs. 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 laboratory services have not been met. Therefore, we decided that the Plan does 
not have to pay for laboratory services (87801, 87481, 87640, 87653, 87651, 87798) provided on April 26, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
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 provided documentation does not support that the enrollee requires services at the 
LTACH that are not available at the acute care hospital where they are currently receiving care. The reviewer 
found that 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. Therefore, the reviewer found that the requested LTACH 
care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics/inserts (L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee has previously received orthotics 
that have helped his pain in both feet and his problem with arthritis. You say that if the enrollee continues with 
the use of custom orthotics, this will eliminate any future foot problems. For this reason, you suggest that the 
enrollee needs a new orthotic to replace the old worn-out orthotics that he has had for many years. 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics/inserts (L3000).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and knee x-ray provided on June 28, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and knee x-ray. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the enrollee must receive care from 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 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 an office visit and knee x-ray provided on June 28, 
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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are considered a major fall risk after your 
surgery and need rehab for stabilization. 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 your 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration. 
 
You asked the Plan to pre-approve bone marrow aspiration. You say that the records provided support the need 
for bone marrow aspiration. The Plan denied your request. The Plan says the clinical value and effectiveness of 
bone marrow aspirate in the setting of spina 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 bone marrow aspiration. Our reviewer 
says that the requested bone marrow aspiration is not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no specific indication provided to support the request for bone 
marrow aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome 
studies to support the use of bone marrow aspirate for this enrollees medical condition as discussed above. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspiration.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has met all her milestones and is just 
sitting in the hospital withering away and is at risk of getting delirium. The Plan denied your request. The Plan 
says the medical records submitted do not establish that the IRF Admission is reasonable and 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 the enrollees medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and 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 acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power lift recliner purchased on May 17, 2022. 
 
You asked the Plan to pay for the power lift recliner. You say that you would like to be reimbursed for the 
equipment you purchased. The Plan denied your request. The Plan says payment cannot be made to a provider 
not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the power lift recliner purchased on May 
17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with the laboratory services for date of 
service December 20, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that this service is medically necessary and 
should be paid. The Plan denied your request. The Plan says the laboratory services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, we find that the testing described by the 
laboratory services is not separately payable. Therefore, we decided that the Plan does not have to pay for 
validity testing billed with the laboratory services for date of service December 20, 2021.