Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral radiofrequency thermotherapy ablation. 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been 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 service. Our physician reviewer 
found the medical records provided do not meet the requirements listed in the LCD for Medicare coverage, 
Specifically, International Prostate Symptom Score (IPSS) greater than or equal to 13 was not provided, 
Maximum urinary flow rate (Qmax) of less than or equal to 15 mL/s (voided volume greater than 125 cc) was 
not provided, and prostate volume was not 30-80 cc. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transurethral radiofrequency thermotherapy ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthetics to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve prosthetics to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 network providers 
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 
prosthetics to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a RomTech portable connect adaptive rehabilitation 
device and remote treatment function device. 
 
You asked the Plan to pre-approve a RomTech portable connect adaptive rehabilitation device and remote 
treatment function device. You say that the item is necessary. The Plan denied your request. The Plan says the 
requested item is not primarily medical in nature. 
 
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 RomTech portable connect adaptive rehabilitation device 
and remote treatment function device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the knee scooter (E0118). 
 
You asked the Plan to pre-approve the knee scooter. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the DME MAC medical directors have reviewed 
information about the products billed using E0118 (crutch substitute). The determination is that there is 
insufficient published clinical literature demonstrating safety and effectiveness in the Medicare population to 
establish the medical necessity for these products. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the knee scooter have not been met. Specifically, this item is not a covered benefit of Medicare or 
the Plan. Therefore, we decided that... Therefore, we decided that the Plan does not have to pre-approve the 
knee scooter (E0118).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided at a 
network facility. 
 
You asked the Plan to pre-approve the SNF care. You say that the SNF is medically necessary, and that the 
enrollee does not meet the criteria for home oxygen with pneumonia. You say that the enrollee needs physical 
and occupational therapy due to unsafe gait and activities of daily living. The Plan denied your request. The 
Plan says authorization denied because the SNF care is not medically necessary and the enrollee's needs can be met at a lower level of care such as home with home health, in residential care, or home with close follow-up 
with their doctor. 
 
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 care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs that require skilled nursing services, including the specialized skill, knowledge and judgment of a 
skilled professional nurse required to safely and effectively provide medically necessary and reasonable 
treatment. There are identifiable skilled therapy service needs that require skilled therapy services, including 
the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide 
medically necessary and reasonable treatment. The enrollee does not require skilled nursing or therapy services 
on a daily basis. As a practical matter, 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 care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) care to be provided at a network facility.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment of $30 for the home INR test kits. We decided that the 
Plan does not have to waive the 4% coinsurance.  
 
You asked the Plan to reduce the cost-sharing for the home INR test kits. You say that you cannot afford the 
$30.00 monthly fee. The Plan says that the cost sharing applied is correct. 
 
We decided that the Plan has to reduce the cost-sharing for medical supplies.  
 
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 enrollees must pay 4% coinsurance for covered medical supplies. These 
charges are from a medical supply company, so the medical supplies coinsurance applies to these claims. 
 
The Plan says you must pay $210, which is $30 copayment per date of service for medical supplies. Based on 
the Plan contract, however, you cannot be asked to pay more than 4% coinsurance for medical supplies. 
Therefore, we decided that the Plan has to reduce the cost-sharing for these supplies from $30 copayment to 
4% coinsurance. 
 
We also decided that the Plan does not have to waive the 4% coinsurance for medical supplies. 
 
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 4% of 
the cost for Medicare-covered medical supply items. Therefore, we decided that the Plan does not have to 
waive the copayment for 4% coinsurance. You are required to pay $25.82, per the table below. 
 
 
Date of Service Service Provided Allowed Amount Cost Share per 
Contract 
Your 
Responsibility 
April 23, 2020 Demonstration of 
Home INR 
$92.04 4% coinsurance  $3.68 
May 28, 2020 Provision of Test $92.30 4% coinsurance $3.69 
June 24, 2020 Provision of Test $92.30 4% coinsurance $3.69 
July 22, 2020 Provision of Test $92.30 4% coinsurance $3.69 
August 19, 2020 Provision of Test $92.30 4% coinsurance $3.69 
September 17, 2020 Provision of Test $92.30 4% coinsurance $3.69 
October 15, 2020 Provision of Test $92.30 4% coinsurance $3.69 
Total:    $25.82 
 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair replacement (K0856). 
 You asked the Plan to pre-approve the wheelchair. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the current power wheelchair is less than 5 years old. Per Medicare rules, a 
replacement due to wear is not covered during the reasonable useful lifetime of the equipment (less than 5 
years). 
 
The Plan must follow Medicare rules. Medicare rules say that The reasonable useful lifetime of durable 
medical equipment is determined through program instructions. In the absence of program instructions, A/B 
MACS (B) may determine the reasonable useful lifetime of equipment, but in no case can it be less than 5 
years. Computation of the useful lifetime is based on when the equipment is delivered to the beneficiary, not 
the age of the equipment. Replacement due to wear is not covered during the reasonable useful lifetime of the 
equipment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-
approve the wheelchair replacement (K0856).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous positive airway pressure (CPAP) device 
(E0601) and humidifier (E0562). 
 
You asked the Plan to pre-approve the CPAP device and humidifier. You say that the item is medically 
necessary. The Plan denied your request. The Plan says you have not seen your physician for a follow-up and 
you have not worn the CPAP as often as you need to.  
The Plan must follow Medicare rules. Medicare rules say that adherence to therapy is defined as use of PAP =4 
hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) 
months of initial usage. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CPAP device and humidifier have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the continuous positive airway pressure (CPAP) device (E0601) and humidifier (E0562).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the mirror workout system (CPT code A9300). 
 
You asked the Plan to pre-approve the exercise equipment. You say that you are too sick to go out in public to 
use your gym and the mirror equipment is necessary for you to exercise. The Plan denied your request. The 
Plan says the requested equipment does not meet the Medicare definition of DME due to it not being medical in 
nature. 
 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 mirror workout system (CPT code A9300).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 23, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim was not billed in accordance 
with Medicare billing regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on April 23, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on July 25, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says that a corrected claim is needed as the 
submitted diagnosis for the rendered services is not consistent for the patient's sex. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has denied coverage for the laboratory services based on 
the billing of the diagnosis code Z79.890 defined as hormone replacement therapy. The Plan states that this 
diagnosis code is inconsistent with the enrollees sex of male. However, there is no explanation as to why a 
billed diagnosis code of hormone replacement therapy would necessarily be invalid for the enrollees biological 
gender. Without this explanation, the denial based on a diagnosis code has not been substantiated. Therefore, 
we decided that the Plan has to pay for the laboratory services provided on July 25, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the True Metrix Glucose Test Strips. 
 
You asked the Plan to pre-approve the True Metrix Glucose Test Strips. You say that the item is medically 
necessary. The Plan denied your request. The Plan says these are not the preferred brand. 
 The Plan follows Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment 
(DME) to only those preferred brands and manufacturers. 
 
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 True Metrix Glucose Test Strips. 
Our reviewer says that the item is not medically necessary. Our physician reviewer found there is no reason 
given why the patient could not learn to use the preferred brand of meters and strips instead of the true metrix 
that he uses or wants to use. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the True Metrix Glucose Test Strips have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the True Metrix Glucose Test Strips.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unlisted otorhinolaryngological service or procedure 
(92700-GN) provided on January 26, 2022. 
 
You asked the Plan to pay for an unlisted procedure. You say that this service was billed correctly as it was 
performed by a speech therapy provider. The Plan denied your request. The Plan says the modifier billed for 
this service is not appropriate for this code. 
 
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 92700 is unlisted otorhinolaryngological service or procedure. 
 
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 an unlisted procedure. Our reviewer says that this service is 
not supported as billed. Our reviewer found that the documentation for this date of service includes an office 
visit. The office visit documents a "High-Resolution Manometry (HRM) with Impedance - Pharynx/upper 
esophageal sphincter (UES). No documentation was found to show another procedure provided, and this 
procedure is being reported with an unlisted procedure code.  
 In this case, if the unlisted procedure reported is the High-Resolution Manometry, then services were billed 
incorrectly. There is a more appropriate code to report for this procedure. Therefore, this procedure and 
modifier was billed incorrectly, and would not be covered. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an unlisted procedure have not been met. Therefore, we decided that the Plan 
does not have to pay for an unlisted otorhinolaryngological service or procedure (92700-GN) provided on 
January 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the BOA click socket (L5999). 
 
You asked the Plan to pre-approve the BOA click socket. You say that the item is medically necessary. The 
Plan denied your request. The Plan says this socket does not have FDA approval and does not meet Medicare 
criteria as safe and effective. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the BOA click socket have not been met. Specifically, you were approved for a basic socket, the 
deluxe socket is not covered. Therefore, we decided that the Plan does not have to pre-approve the BOA click 
socket (L5999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that the item 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 shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing provided on November 16, 2021. 
 
You asked the Plan to pay for lab test. You say that this testing was referred by the in-network physician and 
was useful to make informed decisions about the enrollee's treatment. The Plan denied your request. The Plan 
says that the denial of payment for this testing is correct, because this testing is not covered by Medicare for 
screening purposes. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
This testing was ordered by an in-network physician. The file does not show that the plan provided notice that 
lab test would not be covered. Under Medicare rules, this means lab test is considered approved by the plan. 
Therefore, we decided that the Plan has to pay for laboratory testing provided on November 16, 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the brain for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that a study similar to the one requested has recently been performed. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found there is prior head trauma. 
The Mini Mental State Examination (MMSE) was 27/30 with three points for delayed recall. Due to this 
history, MRI of the brain is reasonable and indicated. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the brain for the enrollee.  
 
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.