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

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the enrollee is falling out of bed 
when sleeping. The Plan denied your request. The Plan says there is no indication that the enrollee has a 
medical condition that requires the need for a semi-electric bed, where positioning is needed and is not feasible 
with an ordinary bed. 
 
 
 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has a past 
medical history including atrial fibrillation, thyroid disease, carotid artery disease and multiple falls. The 
enrollee was evaluated by her primary care provider as a follow-up with multiple falls in the preceding months. 
In this case, the documentation doesnt support that the enrollee has a condition that requires frequent 
positioning of the bed and mattress to alleviate pain, promote good body alignment, prevent contractures or 
avoid respiratory infections in a way that an ordinary bed is not able to. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF services for rehabilitation in 
order to improve their quality of life and return home. The Plan denied your request. The Plan says the request 
is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external upper limb tremor stimulator of the 
peripheral nerves of the wrist (K1018). 
 
You asked the Plan to pre-approve a tremor stimulator. You say that the enrollee has a prolonged and refractory 
bilateral hand essential tremor. The enrollee also has Parkinson's disease, and she needs the medical equipment 
in order to sustain normal life activities. The Plan denied your request. The Plan says the request is not 
medically necessary because records show this treatment is being requested for a motor function disorder. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a tremor stimulator. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the available medical records do not support necessity of the nerve stimulator as 
defined by Medicare criteria. As stated in the National Coverage Determination (NCD) Treatment of Motor 
Function Disorders with Electric Nerve Stimulation, 160.2, "where electric nerve stimulation is employed to 
treat motor function disorders, no reimbursement may be made for the stimulator or for the services related to 
its implantation since this treatment cannot be considered reasonable and necessary." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a tremor stimulator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an external upper limb tremor stimulator of the peripheral nerves of the wrist (K1018).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio nerve stimulator device (K1018, K1019). 
 
You asked the Plan to pre-approve a stimulator device. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says where electric nerve stimulation is employed to treat 
motor function disorders, no reimbursement may be made for the stimulator or for the services related to its 
implantation since this treatment cannot be considered reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a stimulator device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found provided medical records document you most recently have been prescribed 
primidone 100 mg for your tremors; records do not document failure of this medication at this dosage. Also, 
the National Coverage Determination (NCD): Treatment of Motor Function Disorders with Electric Nerve 
Stimulation - 160.2 states: "Where electric nerve stimulation is employed to treat motor function disorders, no 
reimbursement may be made for the stimulator or for the services related to its implantation since this treatment 
cannot be considered reasonable and necessary." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a stimulator device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Cala Trio nerve stimulator device (K1018, K1019).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 10, 2022, billed with 
codes 81162, 81317, 81321, 81334, 81351, 81406, 81437, 81479, 81201, 81209, 81218, 81292, 81295, 81298, 
81307, and 81314. 
 
You asked the Plan to pay for the genetic testing billed. You say that the medical records have been attached to 
this appeal. Please have a look at the attachment and reconsider the charges which were previously denied. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
Screening genetic testing is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 10, 2022, billed with codes 81162, 81317, 81321, 81334, 81351, 81406, 81437, 81479, 81201, 81209, 
81218, 81292, 81295, 81298, 81307, and 81314.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable drug delivery system (A4305) provided from 
December 24, 2020, to December 29, 2020. 
 
You asked the Plan to pay for the disposable drug delivery system. The Plan denied your request. The Plan says 
this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including 
elastomeric infusion pumps (A4305, A4306, A9274) are non-covered devices because they do not meet the 
Medicare definition of durable medical equipment.  
 
We looked at the file and Medicare rules. The requested disposable drug delivery system, coded A4305, is not 
covered per LCA A52507. Based on this information, we decided that Medicare rules for coverage of the 
disposable drug delivery system have not been met. Therefore, we decided that the Plan does not have to pay 
for the disposable drug delivery system (A4305) provided from December 24, 2020, to December 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has moderately severe 
chronic obstructive pulmonary disease (COPD) with an forced expiratory volume (FEV1) of 53 percent of 
predicted in 2021. An arterial blood gas (ABG) study done during an outpatient visit while stable showed mild 
chronic carbon dioxide retention with a partial pressure of carbon dioxide (PCO2) of 53. The criteria for 
coverage are not met and the home ventilator is not reasonable or medically necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
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 you feel that this is the best facility to go to, it 
provides more of what you need, nursing care needed, and it is closer to home verses a drive away. The Plan 
denied your request. The Plan says your current therapy needs can be managed at a lower level of care. 
 
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 continue to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the documentation doesnt support 
that you would meet criteria for admission to an acute inpatient rehabilitation facility. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to be discharged, and requires 
intense rehabilitation. The Plan denied your request. The Plan says based on Medicare guidelines, the requested 
IRF services do not meet the requirements for approval. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lens fitting (92071) provided on August 23, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
billed with the appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that when modifier -50 
is required by manual or coding instructions, claims submitted with 2 lines or 2 units and anatomic modifiers 
will be denied for incorrect coding. 
 
We find that payment for CPT code 92071 is not supported in the medical record. Specifically, this code 
required modifier -50 in this case, as both eyes were treated. 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 the contact lens fitting (92071) provided on August 23, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies provided on September 1, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that the enrollee said 
the supplies were not delivered. 
 
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 Plan argues that the enrollee said the supplies were not delivered. However, 
the records show an itemized packing slip and delivery ticket with the same tracking number. As the 
documentation shows that the items were delivered to the enrollee, the Plan's denial cannot be substantiated. 
Therefore, we decided that the Plan has to pay for the electrical stimulator supplies provided on September 1, 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found you have a diagnosis of age-related osteoporosis. The documentation does not support that you have 
tried and failed Fosamax and Actonel. The documentation does not support that Fosamax and Actonel would 
likely be less be less effective and/or likely have adverse effects for you. Therefore, you do not meet criteria for 
the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 19, 2022, 
to March 20, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 19, 2022, to 
March 20, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies provided on September 1, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that the treating 
provided did not order the supplies. 
 
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 Plan argues that the treating provided did not order the supplies. However, 
the records provided show that the prescription for a life-time need for monthly supplies was signed by the 
treating physician on December 23, 2022, after a visit on September 16, 2020. As such, the Plan's denial cannot 
be substantiated. Therefore, we decided that the Plan has to pay for the electrical stimulator supplies provided 
on September 1, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96127 billed for date of service August 5, 
2022. 
 
You asked the Plan to pay for procedure code 96127. The Plan denied your request. The Plan says payment for 
code 96127 is bundled into payment for code G0439. 
 
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 96127 
is a column II code to column I code G0439 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 96127 billed for date of service August 5, 2022.