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

 
We decided that the Plan does not have to pre-approve a shower chair (E0240), a raised toilet seat (E0244), and 
incontinence supplies (T4527, T4535, T4537, T4541). 
 
You asked the Plan to pre-approve a shower chair, a raised toilet seat, and incontinence supplies. You say that 
the requested items are a medical necessity for you. The Plan denied your request. The Plan says none of the 
requested items is a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs, raised toilet seats, and 
incontinence supplies are not covered because they are not primarily medical in nature or are non-reusable. 
 
While the requested items 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 a shower chair (E0240), a raised 
toilet seat (E0244), and incontinence supplies (T4527, T4535, T4537, T4541).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON MRI. You say that the clinical documentation provided supports 
the need for the requested MRI. The Plan denied your request. The Plan says the facility requested is not 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 network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve an OON MRI.  
 
 
  
Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you believe LTACH is the most 
appropriate level of care for the enrollee. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for LTACH and is not stable for transfer. 
 
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 transfer to LTACH is not medically necessary as the patient is still unstable and 
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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a microprocessor knee for a prosthetic leg. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the notes to support the alleged need for microprocessor knee are nearly verbatim 
those given by the vendor. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. 
 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the clinical documentation by the provider and treatment team specifically states that you require a K3 
level prosthesis. You have specific mobility needs that require the microprocessor knee. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve a microprocessor knee for a prosthetic leg.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve out-of-network hearing aids. You say that this provider is within walking 
distance from your home and has your complete trust as you have used their services before. The Plan denied 
your request. The Plan says out-of-network services are only covered in certain limited circumstances. The 
requested care can be provided in-network by providers within a reasonable distance to you. 
 
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 
hearing aids 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 acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that this member does not have complex nursing and medical management 
needs requiring a resource intensive inpatient hospital setting. 
 
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. 
 The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for respiratory 
failure and COVID pneumonia. The enrollees medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF 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 acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
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 for you 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 (E0240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery backup. 
 
You asked the Plan to pre-approve the backup. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested equipment does not have medical necessity. 
 
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. 
 
A backup battery is not considered a covered benefit as it is duplicative. Therefore, we decided that the Plan 
does not have to pre-approve a battery backup.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve consultation services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the OON consultation services. You say that you need to get surgery as 
soon as possible. You say that you would like to see the requested OON provider because you are comfortable 
with them. The Plan denied your request. The Plan says you have been approved to see an in-network provider 
for endometrial cancer. 
 
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 
consultation services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on January 31, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says an appropriate modifier was not billed with code edit. 
 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 70450 
is a column II code to column I code 70496. 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 imaging services provided to the enrollee on January 31, 2022.
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 disagree with the plan's denial. The 
Plan denied your request. The Plan says you do not meet criteria for the requested device. 
 
The Plan follows Medicare rules. Medicare rules say that a power wheelchair is covered when the enrollees 
home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power 
operated vehicle that is provided.  
 
 The file shows that you do not have a ramp to help you use the power wheelchair. In addition, a ramp cannot be 
installed at your home because there is not enough space. This means you do not meet criteria that states that 
your home must provide adequate access between rooms, maneuvering space, and surfaces for the operation of 
the power operated vehicle. 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services provided to the enrollee on February 10, 2022. 
 
You asked the Plan to pay for the services. You say that the service was provided under the supervision of a 
physician. The Plan denied your request. The Plan says that these codes are reimbursed to anesthesia providers 
only. 
 
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. The provider in this is a certified registered nurse assistant/anesthesia assistant. 
The plan has not provided a rationale as to why this provider would not be appropriate for this service. 
Therefore, we decided that the Plan has to pay for anesthesia services provided to the enrollee on February 10, 
2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ankle foot orthosis (L1940), an addition to lower 
extremity, lacer molded to patient model (L2330) and an addition to lower extremity orthosis, soft interface for 
molded plastic, below knee section (L2820) provided on November 30, 2021. 
 
You asked the Plan to pay for ankle orthotics. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says services without documentation of medical indication from 
the treating provider is not a benefit. 
 The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for an ankle foot orthosis (L1940), an addition to lower extremity, lacer molded to patient model 
(L2330) and an addition to lower extremity orthosis, soft interface for molded plastic, below knee section 
(L2820) provided on November 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha SureClick. 
 
You asked the Plan to pre-approve Repatha SureClick. You say that this drug is medically necessary for the 
enrollee's condition. 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 Repatha SureClick.  
 
 Benefits for Repatha SureClick 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional physical therapy services received from November 
1, 2021, to November 10, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim was already processed. 
 
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 97110 is not supported in the medical record. Specifically, there is no evidence that the 
billed services - CPT 97110 - were rendered twice on the dates of service. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for additional physical therapy services received from November 1, 2021, to November 
10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a venous duplex scan with a vascular surgeon. 
 
You asked the Plan to pre-approve a venous duplex scan. You say that you have been seeing your vascular 
surgeon for 7 years. You say that your primary care physician (PCP) will not submit a request for this service 
because they can do it in their office. You also say that you do not agree with this. The Plan denied your 
request. The Plan says there is no physician order for the requested service. The Plan says that 
 
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 your network Primary Care Physician (PCP). The Plan has confirmed 
with your PCP that the requested service is available in their office now. 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 venous duplex scan with a vascular surgeon.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis (CPT code 0037U) 
provided on December 21, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. The next generation 
sequence testing (NGS) testing panel performed included testing for the FANCC gene. Testing for this gene is 
not a Medicare benefit and is statutorily excluded service. In addition to single gene testing, panels that include 
the FANCC gene are statutorily excluded service. Therefore, we decided that the Plan does not have to pay for 
targeted genomic sequence analysis (CPT code 0037U) provided on December 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for repair recurrent incisional or ventral hernia; reducible (CPT 
code 49565) provided on December 6, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the documentation submitted did not include documentation that repair recurrent incisional or 
ventral hernia; reducible was performed through a separate incision. The Plan states hernia repairs performed at 
the site of an incision for an open or laparoscopic abdominal procedure are considered incidental and are not 
reported separately; therefore, the billed service cannot be verified. 
 
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 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 service. Our reviewer found the reviewed documentation 
indicates that CPT code 49565 80 (1 unit) remains not supported. The documentation submitted did not include 
documentation that repair recurrent incisional or ventral hernia; reducible was performed through a separate 
incision. Of note, hernia repairs performed at the site of an incision for an open or laparoscopic abdominal 
procedure are considered incidental and are not reported separately; therefore, the billed service cannot be 
verified. 
 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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for repair recurrent incisional or ventral hernia; reducible (CPT code 49565) provided on 
December 6, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport provided on January 28, 2021. 
 
You asked the Plan to pay for ambulance transport. You say that the enrollee was on hospice and to reprocess 
accordingly. The Plan denied your request. The Plan says original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
  The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance transport provided on January 28, 2021.