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

 
We decided that the Plan does not have to pre-approve the bag hanger supply (A9270). 
 
You asked the Plan to pre-approve the bag hanger supply. You say that you need this item. The Plan denied 
your request. The Plan says this item does not primarily serve a medical purpose. 
 
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 the bag hanger supply (A9270).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the oximeter (E0445). 
 
You asked the Plan to pre-approve the oximeter. You say that the items is medically necessary. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that Oximeters (E0445) and replacement probes 
(A4606) will be denied as non-covered because they are monitoring devices that provide information to the 
treating practitioner to assist in managing the beneficiarys treatment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oximeter have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the oximeter (E0445).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the manual wheelchair (E1161) and accessories. 
 
You asked the Plan to pre-approve the wheelchair and accessories. You say that the items are medically 
necessary. The Plan denied your request. The Plan says Medicare does not cover durable medical equipment 
(DME) in a skilled nursing facility (SNF) based on statutory definition of DME. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wheelchair and accessories is being requested for use in a SNF or hospital. Therefore, 
we decided that the Plan does not have to pre-approve the manual wheelchair (E1161) and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested power 
wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, and your 
condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652), segmental 
pneumatic trunk (E0656), and Segmental pneumatic appliance (E0669). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the items are medically 
necessary. The Plan denied your request. The Plan says these items are not covered for the treatment of 
lymphedema of the extremities alone. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652), segmental pneumatic trunk (E0656), and Segmental pneumatic appliance (E0669).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hand brake. 
 
You asked the Plan to pre-approve a hand brake. You say that the item should be covered. The Plan denied 
your request. The Plan says the item requested has no medical function and is not a DME item. Additionally, 
you have no diagnosis that would warrant the use of a hand brake. 
 
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 hand brake.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence garments, gloves, ointment, and disposable 
under pads. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says these are not covered items. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence garments, gloves, 
ointment, and disposable under pads.
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 to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH 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 there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. 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. 
 
   
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 the Nova Cruiser De-Light walker. 
 
You asked the Plan to pre-approve the Nova Cruiser De-Light walker. You say that the item is medically 
necessary. The Plan denied your request. The Plan says this walker is not available from a Medicare DME 
(Durable Medical Equipment) provider. It is also considered a convenience. The documentation does not 
indicate that a standard rollator walker or walker with trunk support from a Medicare DME provider will not 
meet your mobility needs. 
 
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 the Nova Cruiser De-Light walker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (PWC) (K0862) and 
accessories. 
 
You asked the Plan to pre-approve a PWC and accessories.. You say that the items are medically necessary. 
The Plan denied your request. The Plan says there is no documentation of a neurological condition, myopathy, 
or congenital skeletal deformity for this member. 
 
The Plan must follow Medicare rules. Medicare rules say that a group 3 PWC is covered if the beneficiary's 
mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a PWC and accessories. have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a group 3 power wheelchair (PWC) (K0862) and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extra portable oxygen concentrator (POC) batteries. 
 
You asked the Plan to pre-approve the POC batteries. You say that the item is medically necessary. The Plan 
denied your request. The Plan says when a portable oxygen concentrator (POC) is authorized, it includes the 
device itself, and an integrated battery or beneficiary-replaceable battery. Medicare does not cover an extra set 
of batteries. 
 
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 the approved POC already includes rechargeable batteries. Therefore, we decided that the 
Plan does not have to pre-approve the extra portable oxygen concentrator (POC) batteries.
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 to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH 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 there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. 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. 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care (99291) provided on March 1, 2021. 
  You asked the Plan to pay for critical care (99291). You say that the providers are a different specialty, and the 
medical records support the service. The Plan denied your request. The Plan says an appropriate modifier was 
not 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 99291 
is a column II code to column I code 36556. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for critical care (99291) provided on March 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 additional months of oxygen (O2) concentrator 
(E1390) and portable oxygen (O2) system (E0431). 
 
You asked the Plan to pre-approve oxygen concentrator and portable oxygen system. You say that please 
approve an additional 9 months rental of o2 for a total of 12 months based on the medical necessity of the 
patient. The Plan denied your request. The Plan says the enrollee does not meet the criteria to be approved for 
O2. The medical records from the provider is not within 30 days of initial certification. 
 The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with significant hypoxemia who meet certain blood gas evidence requirements. In addition, the patient 
must have tried other alternative treatments without complete success. The patient must meet one of the 
following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep; 
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
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 oxygen concentrator and portable 
oxygen system. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found this enrollee has COPD, HFpEF, and recent COVID-
19. The enrollee required oxygen as an inpatient with COVID-19 and was discharged on oxygen in November 
2021. There is oximetry data showing need for oxygen at rest, presumably done prior to discharge, but the date 
is not legible. There is no re-evaluation of oxygen need after discharge. The Plan approved coverage of oxygen 
for 3 months. There are no oximetry measurements breathing room air showing oxygen need since hospital 
discharge in November. Medicare criteria for oxygen need 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 oxygen concentrator and portable oxygen system have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 9 additional months of oxygen (O2) concentrator 
(E1390) and portable oxygen (O2) system (E0431).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray 
(D0220), and root canal (D3330) provided on January 27, 2022, by the out of network provider. 
 
You asked the Plan to pay for the dental services. You say that prior to your root canal you were in a fair 
amount of pain. You say that your primary dentist helped you to find an endodontist. You say that your primary 
dentist also recommended you go to the out of network office because they are familiar with your primary 
dentist's work. The Plan denied your request. The Plan says dental services received out of network are not 
covered. 
 
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, dental services received out of network 
are not among those covered under this benefit. Additionally, the record shows that there is an in network 
provider in the same area. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140), periapical x-ray (D0220), and root canal (D3330) provided on January 27, 2022, by the out 
of network provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retroperitoneal ultrasound (76770) provided on October 
6, 2021. 
 
You asked the Plan to pay for the retroperitoneal ultrasound. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support the service 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 76770 is ultrasound, retroperitoneal (eg, renal, aorta, 
nodes), real time with image documentation; complete. 
 
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 retroperitoneal ultrasound. Our reviewer says that CPT 
code 76770 does not meet criteria for billing or reimbursement consideration. Our reviewer found the procedure report does not include documentation of complete retroperitoneal unltrasound real time with image 
documentation.  The documentation on the second page of the medical record is handwritten and not legible. 
 
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 retroperitoneal ultrasound have not been met. Therefore, we decided that the 
Plan does not have to pay for the retroperitoneal ultrasound (76770) provided on October 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid, digital, binaural, behind the ear (V5261), 
hearing service, miscellaneous (V5299) and dispensing fee, binaural (V5160) provided August 19, 2021. 
 
You asked the Plan to pay for the hearing aids, miscellaneous hearing service and dispensing fee. You say that 
you would like the hearing aids covered. The Plan denied your request. The Plan says the hearing benefit is not 
covered if the services are not registered in advance. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you contact the Plans hearing aid vendor and purchase covered hearing aids from a 
network provider. 
 
We looked at the file and the Plan's rules. The Plan confirmed that you did not contact the customer service 
department or the Plans hearing vendor prior to purchasing the hearing aids. Based on this information, we 
decided that the Plan's rules for coverage of the hearing aids, miscellaneous hearing service and dispensing fee have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid, digital, 
binaural, behind the ear (V5261), hearing service, miscellaneous (V5299) and dispensing fee, binaural (V5160) 
provided August 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the kyphoplasty (22514). 
 
You asked the Plan to pre-approve the kyphoplasty. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty is covered when all of the criteria listed 
in the Medicare Rules section 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 the kyphoplasty. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the MRI report specifically states these 
are chronic and not acute or subacute fractures. 
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the kyphoplasty (22514).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genicular nerve radiofrequency ablation (64624), 
provided on July 15, 2021. 
 
You asked the Plan to pay for the genicular nerve radiofrequency ablation. You say that the service is 
medically necessary. The Plan denied your request. The Plan says this service is experimental. 
 
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 radiofrequency ablation. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this procedure is considered experimental/ investigational as it's role in the management of knee osteoarthritis is still the subject of clinical trials and debate. 
 
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 radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pay for the genicular nerve radiofrequency ablation (64624), provided on 
July 15, 2021.