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 with accessories. 
 
You asked the Plan to pre-approve Group 3 power wheelchair. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this device is correct, 
because the enrollee does not have a qualifying diagnosis for a Group 3 power wheelchair. 
 
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 
Group 3 power wheelchair with accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve the power scooter. You say that the power scooter is medically necessary. 
The Plan denied your request. The Plan says this device is for use outside the home and is non-covered. The 
record shows the power scooter is to be stored in a van and there is no ramp to access the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a car lift for a power scooter (E1399). 
 
You asked the Plan to pre-approve the car lift. You say that this device is medically necessary to transport the 
scooter to doctor's appointments. The Plan denied your request. The Plan says a car lift is not primarily medical 
in nature and is non-covered. 
 
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 a car lift for a power scooter (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy testing. 
 
You asked the Plan to pre-approve bioimpedance spectroscopy. You say that use of this technology is 
medically necessary to monitor the enrollee's condition. The Plan denied your request. The Plan says the denial 
of authorization for this service is correct, because bioimpedance spectroscopy is experimental/investigational. 
 
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 bioimpedance spectroscopy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found a review of current medical literature indicates that bioimpedance 
spectroscopy is considered experimental and investigational. It is not identified as widely used and generally 
accepted for the proposed 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 bioimpedance spectroscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bioimpedance spectroscopy testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra 5% drops. 
 
You asked the Plan to pre-approve Xiidra 5% drops. You say that this drug is medically reasonable and 
necessary. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
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 Xiidra 5% drops.  
 
Benefits for Xiidra 5% drops may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve carbidopa-levodopa tablets (J3490 x 12). 
 
You asked the Plan to pre-approve carbidopa-levodopa tablets. You say that the requested drug is necessary. 
The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says 
self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare Part B. 
 
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 carbidopa-levodopa tablets 
(J3490 x 12).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you have severe weakness on your entire 
left side of your body. You say that you want to try rehabilitation to see if you can be an independent person again. You also say that your family is not equipped to handle your situation. The Plan denied your request. 
The Plan says the SNF admission is not medically necessary. 
 
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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require daily 
skilled nursing services. The reviewer found that while the enrollee may require skilled therapy services, they 
do not require them on a daily basis. The reviewer also found that the enrollee does not meet severity of illness 
or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hyperthermia treatment rendered on September 14, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the submitted records do not support the billing of the -59 modifier. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
We asked our coder 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 these services Our reviewer says that the 
submitted records do not support the billing of the -59 modifier. Our coder reviewer found the procedure was 
billed with modifier -59 as a distinct procedure service and -XE for a separate encounter. Modifier -59 is not 
appropriate to report with -XE. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the hyperthermia treatment rendered on September 14, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the angiography (75710) provided on April 24, 2021. 
 
You asked the Plan to pay for the angiography. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that an edit exists between CPT codes 75710 
and 37225 
 
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, we have confirmed that code 75710 
is a column II code to column I code 37225; however, 75710 was billed with a modifier. 
 
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 angiography. Our reviewer says that CPT code 75710 
meets criteria for billing and reimbursement consideration. Our reviewer found the procedure report describes a 
diagnostic angiography was performed, prior to the intervention. In this case, CPT 75710 if appended with 
modifier 59 would be reported separately. 
 
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 angiography have been met. Therefore, we decided that the Plan has to pay 
for the angiography (75710) provided on April 24, 2021.  
 
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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
service is medically necessary. Our physician reviewer found you do not have documented skilled nursing 
needs. You do have documented skilled therapy needs. You are functioning below your baseline. The 
documentation does not yet show that you have reached a new, lower level of function. Therapy to improve 
your ability to transfer and assist with ADLs is reasonable. Daily skilled services are required to establish a 
maintenance program or to prevent deterioration of your 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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic facet joint injections. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic facet joint injections are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have chronic 
thoracic spine pain without true radiculopathy (pinching of the nerve roots). You have had radiofrequency 
ablation (RFA) in the past. You underwent injections on May 18, 2021 and November 22, 2021. There is no 
documentation supporting that you are not a candidate for RFA. There is no physical exam that shows the facet 
joint as the source of the pain. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve therapeutic facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a glucose monitoring system (A9276). 
 
You asked the Plan to pre-approve the glucose monitoring system. You say that this device is medically 
necessary. The Plan denied your request. The Plan says the requested device is considered a non-therapeutic 
continuous glucose monitor and is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a 
therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit).   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the glucose monitoring system have not been met. Specifically, the requested CGM device does 
not meet the definition of a therapeutic CGM. Non-Therapeutic CGMs are not covered by Medicare or the 
Plan. Therefore, we decided that the Plan does not have to pre-approve a glucose monitoring system (A9276).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a new patient office visit provided on 
September 10, 2021. 
 
You asked the Plan to waive the deductible for an office visit. You say that your primary care ordered 
bloodwork, and it should be covered. You also say that the hospital was listed as a participating provider. The 
Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is an out of network $1,500 deductible which applies to an out of network 
office visit.  
 
The Plan confirmed the hospital you received services at on September 10, 2021, is an out of network provider. 
The deductible had not been met at the time of service. The item or service you asked the Plan to waive the 
deductible for falls within the Physician/Practitioner Services, Including Doctors Office Visits benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,500 
deductible which applies to office visit. This cost sharing is a contractual obligation that had not been met at the time an office visit was received on September 10, 2021. Therefore, we decided that the Plan does not have 
to waive the deductible for a new patient office visit provided on September 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services (29823) provided on November 17, 
2021. 
 
You asked the Plan to pay for code 29823. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as 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, we have confirmed that code 29823 cannot be paid due to a bundling issue. We note the Plan paid 
for code 29827 as this was billed correctly. Medicare billing criteria have not been met. Per the National 
Physician Fee Schedule, CPT codes 29827 and 29823 have the same Endo base of 29805. Payment for CPT 
29823 is bundled. Therefore, we decided that the Plan does not have to pay for the surgical services (29823) 
provided on November 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the permanent percutaneous insertion of STIMQ 
peripheral nerve stimulator (PNS). 
 
You asked the Plan to pre-approve the STIMQ PNS. You say that you would like reconsideration because the 
requested procedure is medically necessary. The Plan denied your request. The Plan says this request does not 
meet Medicare criteria for coverage. 
 
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 STIMQ PNS. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is an experimental/ investigational procedure for the treatment of knee pain. 
 
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 STIMQ PNS have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the permanent percutaneous insertion of STIMQ peripheral nerve stimulator (PNS).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after 
March 27, 2022. 
 
You asked the Plan to pre-approve SNF care. You say that this discharge is too soon and the enrollee still 
requires 24-hour care and physical therapy. The Plan denied your request. The Plan says the denial of 
authorization for continued SNF care is correct.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) setting. 
 
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 continued skilled nursing facility (SNF) care after March 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-Phillips brand continuous positive air pressure 
(CPAP) machine. 
 
You asked the Plan to pre-approve a non-Phillips brand CPAP machine. You say that you received a 
replacement but it is the same brand as the previously recalled device and it is detrimental to your health. You 
would like another brand. The Plan denied your request. The Plan says the recalled device has been replaced 
with a functioning CPAP machine. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a functioning CPAP machine not affected by the recall. This device serves the 
same purpose as the requested non-Phillips brand replacement. Therefore, we decided that the Plan does not 
have to pre-approve a non-Phillips brand continuous positive air pressure (CPAP) machine.