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

 
We decided that the Plan does not have to pre-approve a power tilt system (E1002). 
 
You asked the Plan to pre-approve a power tilt system. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are covered when 
certain 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 a power tilt system. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the power tilt system and 
associated electronics are not medically necessary. The enrollee does not require power tilt per Medicare rules 
as he does not have high risk of skin breakdown, rely on intermittent catheterization or have spasticity 
requiring special positioning. 
 
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 power tilt system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power tilt system (E1002).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission 
criteria, and you are requesting reconsideration based on the records submitted. The Plan denied your request. 
The Plan says that the enrollee does not meet Medicare guidelines for care in an LTACH. 
 
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 that there are no services available at the LTACH that the enrollee requires that are 
not already available and covered at the current facility. Transfer to the LTACH is not medically necessary as it 
would not be clinically advantageous. Completion of treatment at the current facility is recommended. 
 
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the outpatient service. You say that the enrollee is very sick and has a bad 
back. You also say that the enrollee needs help with activities of daily living. The Plan denied your request. 
The Plan says the requested service is not urgent or emergent in nature. The Plan also says the requested 
service can be provided in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has confirmed there is a 
network provider available who can provide the items/services at issue in this appeal. We found no exception 
that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not 
have to pre-approve a consultation to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that your prognosis is poor if the requested IRF 
admission is not approved. The Plan denied your request. The Plan says you do not meet all the requirements 
for an IRF admission. 
 
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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from August 22, 2021, to 
August 28, 2021. 
 
You asked the Plan to pay for the inpatient services. You say that you are requesting that the Plan vacate their 
dismissal of appeal action. The Plan denied your request. The Plan says with the information provided, it 
cannot be determined how the enrollee came to the servicing provider, or whether the services are medically 
necessary. 
 
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 inpatient services have been met. 
Medical records were not provided with this case. The record shows that the Plan made multiple attempts to 
obtain this information, but it was not received. Without medical records we are unable to determine if the 
services provided were medically necessary. Therefore, we decided that the Plan does not have to pay for the 
inpatient services provided from August 22, 2021, to August 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 15, 2021, billed with 
codes 95938 and 95957. 
 
You asked the Plan to pay for the medical services as billed. You say that the claim should be paid as billed. 
The Plan denied your request. The Plan says some of the billed services were approved on appeal; however, 
95957 and 95938 are not supported. 
 
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 95938 is short-latency somatosensory evoked potential 
study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper 
and lower limbs. The definition for code 95957 is digital analysis of electroencephalogram (EEG) (eg, for 
epileptic spike analysis). 
 
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 medical services as billed. Our reviewer says that the 
documentation does not support that the services described by these codes were performed. Our reviewer found 
the procedure report does not provide clear documentation to support that the short-latency somatosensory 
evoked potential studies billed were provided to support reporting 95938. In addition, the type of EEG testing 
described by code 95957 is not documented. 
 
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 medical services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the medical services provided on July 15, 2021, billed with codes 95938 and 
95957.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
system. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. The Plan denied your request. The Plan says the 
enrollee has not met the medically necessary criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle 
Libre continuous glucose monitor (CGM) system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair (K0003). 
 
You asked the Plan to pre-approve a lightweight wheelchair. You say that you disagree with the denial and 
request reconsideration. Your walker has no breaks and the front wheel falls off frequently and is not 
dependable. The Plan denied your request. The Plan says the records submitted does not meet the Medicare 
LCD guidelines criteria. 
 
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. A home assessment was not completed to show that a wheelchair will 
be able to maneuver in the home. Notes show that the wheelchair assessment was cancelled on December 21, 
2022. Based on this information, we decided that Medicare rules for coverage of a lightweight wheelchair have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a lightweight wheelchair 
(K0003).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay the x-ray coded 73630 provided on September 12, 2022. 
 
You asked the Plan to pay the x-ray coded 73630. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says this code is not payable 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. 
 
We find that CPT code 73630 is not supported in the medical record. Specifically, this code was not billed with 
an anatomical modifier. This means this code is not payable as billed. Based on this information, we decided 
that Medicare rules for coverage of the x-ray coded 73630 have not been met. Therefore, we decided that the 
Plan does not have to pay the x-ray coded 73630 provided on September 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on October 3, 2022. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says your benefit for 
the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 22, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - problem focused 
(D0140) provided on October 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve behavioral health inpatient services. 
 
You asked the Plan to pre-approve behavioral health inpatient services. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 behavioral health inpatient services.  
 Our reviewer says that the documentation does not support that the requested services are medically reasonable 
or necessary. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric 
hospitalization on February 14, 2023, with Delirium. The documentation does not support that it is medically 
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a 
lower level of care as the enrollee did not have dangerousness to self or others, perceptual disturbance 
including delusions, auditory or visual hallucinations. The enrollee is noted to be cooperative and compliant 
with treatment while not showing any aggressive behaviors as the enrollee awaited placement. Therefore, the 
enrollee does not meet criteria for the requested 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 behavioral health inpatient services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve behavioral health inpatient services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CGM and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the requested items are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections and do not require frequent self-adjustment of insulin dosage based on the blood glucose 
testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a CGM and supplies.
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 inpatient service is medically necessary to lead a 
normal life and regain the strength. The Plan denied your request. The Plan says the services you need can be 
provided safely in other settings, a skilled nursing facility, home with home health services or home with 
outpatient therapy. 
 
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 you do not require treatment by multiple therapies, including either physical or 
occupational therapy, and an intensive rehabilitation therapy 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Aranesp. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that you have tried and failed the required drugs. There is no indication that the plan's 
required drugs would likely be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service July 19, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service July 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81291). 
 
You asked the Plan to pre-approve genetic testing. You say that the requested test is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested test is non-covered for thrombophilia. 
There is broad consensus in the medical literature that MTHFR genotyping has no clinical utility in any clinical 
scenario. This testing is considered investigational and is not a Medicare benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that this testing is considered investigational and is 
not a Medicare benefit. 
 
We looked at the file and Medicare rules. Medicare rules confirm this test is considered investigational and it is 
not a covered benefit. Based on this information, we decided that Medicare rules for coverage of genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing (81291).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare criteria for admission to an IRF. The enrollee's needs can be met at a lower 
level of care such as skilled nursing facility (SNF), home with home health services or home with outpatient 
therapy. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive 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 IRF admission and services.