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

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that the requested 
group 3 power wheelchair and accessories are medically necessary. The Plan denied your request. The Plan 
says the enrollee does not meet criteria for the requested group 3 power wheelchair and accessories. 
 
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 a group 3 power wheelchair and 
accessories. Our reviewer says that the enrollee does not meet criteria for the requested group 3 power 
wheelchair and accessories. Our physician reviewer found the documentation indicates the enrollee has a 
mobility deficit. The documentation indicates that the enrollee's mobility deficit can safely and effectively be 
helped with a manual wheelchair. A June 26, 2022, evaluation notes that this enrollee can navigate her wheelchair in the apartment without difficulty and safely complete all activities of daily living in her manual 
wheelchair. While the enrollee may be able to safely maneuver a power wheelchair the requested K0861 
wheelchair and accessories (K0861 x1, E1007 x1, E2620 x1, E1028 x1, E1012 x1, E2377 x1, E2313 x1, E2622 
x1) exceed her needs. 
 
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 group 3 power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve the injections. You say that the requested services are medically necessary. 
The Plan denied your request. The Plan says the requested services are medically necessary.  
The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered 
medically reasonable and necessary for patients who have had two medically reasonable and necessary 
diagnostic facet joint procedures with each one providing a consistent minimum of 80% relief of primary 
(index) pain. 
 
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 injections. Our reviewer says that 
the requested injections are not medically necessary. Our physician reviewer found the provided documentation 
indicates that the enrollee has previously received facet joint injections. The reviewer found that the enrollee 
only experienced 15% pain relief for a short period of time. Therefore, the reviewer found that the requested 
injections 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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections (64493, 64494).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 7, 2021. 
 
You asked the Plan to pay for the lab services. You say that your lab is licensed and these services should be 
paid. The Plan denied your request. The Plan says without the requested documentation, the provider's 
licensure cannot be confirmed.  Also, medical records were requested multiple times with no response. 
 
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 lab services provided on December 7, 
2021. have been met. Specifically, you have supplied no medical records to support payment for these services despite the Plan requesting them from you multiple times.  Without records, we cannot determine if these 
services are payable. Therefore, we decided that the Plan does not have to pay for lab services provided on 
December 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimal residual disease (MDR) testing for cancer 
(81479). 
 
You asked the Plan to pre-approve MDR testing. You say that this test is medically necessary and all cancer 
types have been approved for this test by the FDA as of November 2021. The Plan denied your request. The 
Plan says this test is not FDA approved for your condition. 
 
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 MDR testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that the requested testing is demonstrated to identify 
molecular recurrence or progression before there is clinical, biological, or radiographical evidence of 
recurrence or progression, and demonstrates sensitivity and specificity of subsequent recurrence or progression 
comparable with or superior to radiographical or other evidence (as per the standard-of-care for monitoring a 
given cancer type) of recurrence or progression. It is not documented that there is clinical validity of its results 
in published literature for the explicit management or therapy indication. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MDR testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve minimal residual disease (MDR) testing for cancer (81479).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on February 14, 2022. 
 
You asked the Plan to pay for the testing services. You say that all services were properly ordered. The Plan 
denied your request. The Plan says panels of 6 or more pathogens are non-covered. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Panels with greater than 5 pathogens are not medically reasonable or 
necessary. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the panel testing provided on February 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genicular nerve block provided on May 6, 2022. 
 
You asked the Plan to pay for the genicular nerve block. You say that the genicular nerve block provided on 
May 6, 2022, was medically necessary. The Plan denied your request. The Plan says the genicular nerve block 
provided on May 6, 2022, 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 the genicular nerve block. Our reviewer says 
that the genicular nerve block provided on May 6, 2022, was not medically necessary. Our physician reviewer 
found this is considered an experimental/ investigational procedure. The role of genicular nerve blocks and 
radiofrequency ablation (RFA) for the therapy of knee osteoarthritis is still being evaluated. Therefore, the 
procedure was considered 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pay for the genicular nerve block provided on May 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on March 29, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you were seen only for your annual 
physical examination and the visit should have been covered in full. The Plan denied your request. The Plan 
says the copayment applied is correct. 
 
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 $10 
copayment for each covered visit or consultation in an outpatient location with your PCP or other primary care 
provider.  You have been asked to pay a $10 copayment for an office visit. An office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits, 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 an office visit provided on March 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service December 8, 
2021. 
 
You asked the Plan to pay for procedure code 36000. The Plan denied your request. The Plan says procedure 
code 36000 is considered bundled and not separately payable. 
 
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 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 36000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36000 billed for date of service December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 28, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the facility claim. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for inpatient hospital services 
under the Inpatient Prospective Payment System (PPS). These amounts are, with certain exceptions, payment in 
full to the hospital for inpatient operating costs. All items and non-physician services furnished to inpatients 
must be furnished directly by the hospital or billed through the hospital under arrangements.  
 
We looked at the file and Medicare rules. Payment for the requested services is included in the base payment to 
the facility. Separate payment cannot be made for these services. 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 the services provided on March 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the Vertiflex device. You say that the requested Vertiflex device is 
medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device 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 Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the Vertiflex 
device is experimental. More research is needed. At this time the device is 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 Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Upwalker Oasis Space 12 Inch Pneumatic Upright 
All Terrain UP Rollator with Seat and Armrest. 
 
You asked the Plan to pre-approve a walker. You say that the enrollee would benefit from the upright walker 
because she has a history of bilateral shoulder replacements, neuropathy, and undifferentiated inflammatory 
arthritis. The Plan denied your request. The Plan says the requested device does not meet criteria for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a walker. 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 
requested device is not proven to safe and effective for the enrollee's condition. The enrollee has a history of 
neuropathy, and the documentation notes she has balance issues. The documentation is not clear that this 
device will be safe for her to use. 
 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 walker have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an Upwalker Oasis Space 12 Inch Pneumatic Upright All Terrain UP Rollator with Seat and 
Armrest.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospitalization provided from March 6, 2021, to 
March 7, 2021. 
 
You asked the Plan to pay for the inpatient hospitalization. You say that you believe this request was denied in 
error, and would like this claim to be reconsidered. The Plan denied your request. The Plan says the 
information now received does not support that the criteria were met for inpatient hospitalization. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient hospitalization. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found based on how stable this enrollee was according to the documentation, there was no 
suggestion that the continued workup and monitoring would require hospital services that would likely cross 2 
midnights. 
 
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 inpatient hospitalization have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospitalization provided from March 6, 2021, to March 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Monocentric hydraulic hip joint. 
 
You asked the Plan to pre-approve a Monocentric hydraulic hip joint. You say that the requested Monocentric 
hydraulic hip joint is medically necessary. The Plan denied your request. The Plan says the requested 
Monocentric hydraulic hip joint 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 a Monocentric hydraulic hip joint. Our 
reviewer says that the requested Monocentric hydraulic hip joint is not medically necessary. Our physician 
reviewer found the documentation does not include treating medical physician documentation of the enrollee's 
current functional status and the need for the requested hydraulic hip joint. There is no recent objective gait or 
functional evaluation. The documentation is not clear that this hydraulic hip joint is being furnished in a setting 
appropriate to the enrollee's medical needs and condition or whether this hydraulic hip joint exceeds the 
enrollee's medical and functional needs. 
 
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 Monocentric hydraulic hip joint have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Monocentric hydraulic hip joint.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care provided from June 30, 
2022, to July 6, 2022. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the provided documentation indicates by June 30, 2022, you had stable 
vitals, tolerated room air, and appropriate for a lower level of care rather than staying at the inpatient level of 
care. Therefore, the reviewer found there was no suggestion that you would require an extended hospital stay 
that would likely cross 2 midnights to justify this request. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care provided from June 30, 2022, to July 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation discharge services provided on March 26, 
2022, billed with code 99217. 
 
You asked the Plan to pay for the observation discharge services. You say that this is payable in the emergency 
place of service. The Plan denied your request. The Plan says this is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that only the physician responsible for the patient 
during his/her observation care is allowed to bill the observation codes. When the enrollee is admitted to observation and discharged the next calendar day, both the initial and discharge observation codes are billed on 
the respective dates of service. 
 
We looked at the file and Medicare rules. The Plan notes that the physician at issue did not bill the initial 
observation code. This initial code must be billed by the same physician in order to be paid for the discharge 
code. Based on this information, we decided that Medicare rules for coverage of the observation discharge 
services have not been met. Therefore, we decided that the Plan does not have to pay for the observation 
discharge services provided on March 26, 2022, billed with code 99217.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22513 and 22515). 
 
You asked the Plan to pre-approve kyphoplasty. You say that the requested kyphoplasty is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested kyphoplasty. 
 
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 kyphoplasty. Our reviewer says that the 
enrollee does not meet criteria for the requested kyphoplasty. Our physician reviewer found there is no 
documentation showing imaging studies that show that the fractures are less than 12 weeks old. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22513 and 22515).