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

 
We decided that the Plan has to pre-approve the upgraded electronics. We decided that the Plan does not have 
to pre-approve the seat elevator and power standing system.  
 
You asked the Plan to pre-approve the upgraded electronics, seat elevator and power standing system. You say 
that please process the attached preservice appeal. This is the second time you have sent the request. Please 
process. The Plan says that the requested seat elevator, power standing system, expandable controller, 
accessory and harness exceed the member's need and cannot be approved. 
 
We decided that the Plan has to pre-approve the upgraded electronics.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 upgraded electronics, seat elevator 
and power standing system. Our reviewer says that the requested items/services are considered medically 
reasonable and necessary in this case. Our physician reviewer found the clinical documentation shows upper 
limb limitations due to multiple injuries and chronic pain syndrome thus expandable controller (E2377) harness 
(E2313) electronic connection between wheelchair controller and two or more power seating system motors 
(E2311) is 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 upgraded electronics, seat elevator and power standing system have been 
met. Therefore, we decided that the Plan has to pre-approve the upgraded electronics.  
 
We also decided that the Plan does not have to pre-approve the seat elevator and power standing system. 
 
The Plan follows Medicare rules. The rules say that a power seat elevation feature (E2300) and power standing 
feature (E2301) are non-covered because they are not primarily medical in nature. Based on this information, 
we decided that Medicare rules for coverage of seat elevator and power standing system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the seat elevator and power standing 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient services provided from February 10, 2021, through 
February 13, 2021 with the reported principal diagnosis E22.2, syndrome of inappropriate secretion of 
antidiuretic hormone. 
 
You asked the Plan to pay for inpatient services provided from February 10, 2021, through February 13, 2021 
with the reported principal diagnosis E22.2, syndrome of inappropriate secretion of antidiuretic hormone. The 
Plan denied your request. The Plan says that the claim recouped and adjusted with 140 DRG updated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with the reported principal diagnosis E22.2, syndrome of 
inappropriate secretion of antidiuretic hormone. 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 
inpatient services provided from February 10, 2021, through February 13, 2021 with the reported principal 
diagnosis E22.2, syndrome of inappropriate secretion of antidiuretic hormone. Our reviewer says that the 
documentation supports that the inpatient care is payable as billed. Our physician reviewer found that the 
principal diagnosis E22.2, syndrome of inappropriate secretion of antidiuretic hormone is supported by the 
medical records. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
services provided from February 10, 2021, through February 13, 2021 with the reported principal diagnosis 
E22.2, syndrome of inappropriate secretion of antidiuretic hormone.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants on tooth #22, 24, 26, and 27 
(D6010). 
 
You asked the Plan to pre-approve implants. You say that these services are medically necessary. The Plan 
denied your request. The Plan says endosteal implants (D6010) are not covered by your dental benefits. 
 
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 pre-approve 
endosteal implants on tooth #22, 24, 26, and 27 (D6010).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the EpiFix (MiMedx) amniotic membrane allograft. 
 
You asked the Plan to pre-approve the EpiFix (MiMedx) amniotic membrane allograft. You say that the EpiFix 
(MiMedx) amniotic membrane allograft is medically necessary. The Plan denied your request. The Plan says 
that the EpiFix (MiMedx) amniotic membrane allograft is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 EpiFix (MiMedx) amniotic 
membrane allograft. Our reviewer says that the requested EpiFix (MiMedx) amniotic membrane allograft is 
considered medically reasonable and necessary in this case. Our physician reviewer found it is well established 
that you have been suffering with an ulceration to the right hallux for greater than six months. Imaging 
demonstrates no signs of osteomyelitis. You have undergone multiple rounds of oral antibiotics due to 
infection, daily dressing changes, and routine debridement with offloading. Unfortunately, the ulceration has 
not healed. For this reason, your physician has recommended EpiFix covering for the ulceration. Medicare 
advises that they indeed pay for items or services that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury or to improve the functioning of a malformed body member. This treatment 
must be safe and effective, not mainly for the convenience of the patient or the physician, not experimental or 
investigational, and appropriate  furnished in accordance with accepted standards of medical practice for the 
diagnosis or treatment of the patients condition. It is well established in the medical documentation that you 
have undergone significant conservative and standard of care treatments for the ulceration to the right hallux 
without resolution. EpiFix is approved for the treatment of diabetic ulcerations, which is what you are suffering 
with. Your chronic ulceration to the right hallux meets Medicare criteria for medically reasonable and 
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 EpiFix (MiMedx) amniotic membrane allograft have been met. Therefore, 
we decided that the Plan has to pre-approve the EpiFix (MiMedx) amniotic membrane allograft.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing provided on January 13, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the MolDX Team has determined that testing for 
the FANCC is not a Medicare benefit and is a statutorily excluded service. In addition to single gene testing, 
MolDX will also deny panels of tests that include the FANCC gene.  
 
We looked at the file and Medicare rules. Per LCA A53628, the requested FANCC genetic testing is not a 
covered benefit. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the FANCC genetic testing provided on 
January 13, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coronavirus testing (U0003, U0005) provided on April 
18, 2021. 
 
You asked the Plan to pay for the laboratory testing. You say that the medically necessary services were 
rendered to the enrollee in good faith. 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 coronavirus testing (U0003, U0005) provided on April 
18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid assessment (V5010), hearing aid 
fitting/checking (V5011), and hearing aid or assistive listening device/supplies/accessories (V5267) provided 
on December 28, 2021. 
 
You asked the Plan to pay for the hearing aid assessment, hearing aid fitting/checking, and hearing aid or 
assistive listening device/supplies/accessories. The Plan denied your request. The Plan says the billed services 
are not supported. 
 
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 the hearing aid assessment (V5010), 
hearing aid fitting/checking (V5011), and hearing aid or assistive listening device/supplies/accessories (V5267) 
provided on December 28, 2021. have been met. Specifically, no medical records were provided to show what 
services were rendered, or to support the services that were rendered. Therefore, we decided that the Plan does 
not have to pay for the hearing aid assessment (V5010), hearing aid fitting/checking (V5011), and hearing aid 
or assistive listening device/supplies/accessories (V5267) provided on December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) and urinalysis (81003) provided on 
December 22, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and urinalysis. You say that similar services provided to this 
enrollee have been paid for in the past. The Plan denied your request. The Plan says the services were provided 
out-of-network and were not approved in advance. 
  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 office visit (99204) and urinalysis (81003) 
provided on December 22, 2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide (HHA) services, 2 hour per day, 14 
hours per week, from June 19, 2022, to August 18, 2022. 
 
You asked the Plan to pre-approve home health services. You say that you have a broken back and toes. You 
say that you have low potassium. You say that you are not able to move at times. You also say that you need 
help with cooking and cleaning still. The Plan denied your request. The Plan says the home health aide services 
are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 home health services. Our reviewer 
says that the requested home health services are not medically necessary. Our physician reviewer found the 
services of a home health aide are not shown to be medically necessary and reasonable to assist in the treatment 
of illness or injury. The reviewer found that the enrollees care needs appear to be custodial. Therefore, the 
reviewer found that the requested services 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health aide (HHA) services, 2 hour per day, 14 hours per week, from June 
19, 2022, to August 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) for the left hand provided on 
March 1, 2022. 
 
You asked the Plan to pay for a wrist-hand orthosis. You say that the item at issue was a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the enrollees medical record adequately supports the medical necessity for the item. 
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the available medical records do not discuss the item at issue. Therefore, we decided 
that the Plan does not have to pay for a wrist-hand orthosis (L3916) for the left hand provided on March 1, 
2022.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for Aminolevulinic acid hcl. We decided that the Plan 
does not have to waive the copayment for a specialist office visit.  
 
You asked the Plan to waive the copayment for a specialist office visit and the coinsurance for Aminolevulinic 
acid hcl. You say that that this is the third time you have had this procedure to remove potential cancer from 
your face. You also say that the first two times this procedure was done, you only had to pay a $40 copayment. 
The Plan says that you were charged the correct cost sharing amount. 
 
 We decided that the Plan has to waive the coinsurance for Aminolevulinic acid hcl .  
 
Medicare rules say that 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 mentions there is a $50 
copayment for drugs provided at a pharmacy, but has no mention of the cost of drugs provided by a 
physician/practitioner. You can find this information on pages 111-112 of the Plans 2022 EOC. Therefore, we 
decided that the Plan has to waive the coinsurance for Aminolevulinic acid hcl .  
 
We also decided that the Plan does not have to waive the copayment for a specialist office visit. 
 
We decided that the Plan does not have to waive the copayment for a specialist office visit for topical 
administration provided on March 31, 2022. 
 
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 $40 
copayment for each specialists office visit.  
 
You have been asked to pay a $40 copayment for a specialist office visit. A specialist office visit falls within 
the outpatient surgery, including services provided at hospital facilities and ambulatory surgical centers 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 a specialist office visit provided on March 31, 
2022. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that there is no documentation of medical complexity 
or preoperative risk to warrant admission. 
 
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 inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. The member has a 
history of hypertension, thyroid disease, and osteoarthritis. Documentation does not show any significant medical condition or complexity necessitating inpatient hospitalization admission. Our physician reviewer 
found that the enrollee's condition does not meet criteria for coverage of inpatient hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Knee orthosis (L1852). 
 
You asked the Plan to pre-approve the orthosis. You say that the brace will help take some pressure off the 
medial joint space to decrease pain. The enrollee should try all conservative measures to prolong a total knee 
arthroplasty until she is fully ready. The Plan denied your request. The Plan says the records do not support that 
the orthosis is 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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, the enrollee has not had recent surgery or a recent injury. The documentation 
doesnt support that the joint is unstable or that there is joint laxity. The requested knee orthosis 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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Knee orthosis (L1852).