Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two skilled nursing visits. 

You asked the Plan to pre-approve home health services. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
provided records do not document any acute or unstable medical conditions or changes in medication or 
treatment which would necessitate any further skilled nursing visits beyond what have already been approved. 
The records document the enrollee/caregiver have been educated on the disease process, medications, oxygen, 
and home safety. There are no medical notes from the enrollee's treating physician are provided documenting 
an order or need for additional skilled nursing services beyond what have been approved by the Plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve two skilled nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve group 3 power wheelchair and accessories coded as 
K0861, E0955, E1007, E1012, E1020, E1028, E2311, E2313, E2361, E2377, E2622, K0040 and K0108. 
 
You asked the Plan to pre-approve the power wheelchair. You say that the conflicting documentation from the 
provider should not keep you from getting your wheelchair that you need so much. The Plan denied your 
request. The Plan says the enrollee does not have a medical need for a group3 power wheelchair with the 
requested power options/features. 
 
The Plan follows Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: a neurological condition, myopathy or a congenital 
skeletal deformity. 
 
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 power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is non-ambulatory due to transtibial amputation and cannot use a 
prosthesis. The enrollee cannot use a cane or walker for mobility. The enrollee does not have significantly 
impaired cardiac function based on their last echocardiogram. There is conflicting documentation from the 
enrollees physician and the mobility evaluation as to whether they can adequately propel a manual wheelchair 
for mobility and performing daily activities. Even if the enrollee requires a power wheelchair for mobility it is 
not clear that the enrollee requires a group 3 power wheelchair with power tilt and recline and power elevating 
leg rests. These are typically reserved for patients with significant neurological conditions such as spinal cord 
injury, traumatic brain injury or myopathies such as muscular dystrophy. The enrollee is noted to have 4/5 
motor strength in the upper extremities and power tilt and recline would be required for a pressure wound on 
the trunk or pelvis, not the lower extremity. Additionally, the enrollee is not noted to have lower extremity 
lymphedema or spasticity and require power elevating leg rests. Therefore, the group 3 power wheelchair with 
power tilt and recline and power elevating leg rests is not 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 the power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve group 3 power wheelchair and accessories coded as K0861, E0955, E1007, 
E1012, E1020, E1028, E2311, E2313, E2361, E2377, E2622, K0040 and K0108.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies A4595 provided on October 
20, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the items provided are not supported. 
 
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 proof of delivery for the supplies provided in this case. Review of the file 
shows that the proof of delivery did not include an order number or details to corroborate the delivery ticket 
submitted. In addition, the proof of delivery is not itemized to indicate the specific supplies. 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 the electrical stimulator supplies A4595 provided on October 20, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care following the surgery (27447). 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay is medically necessary. The 
Plan denied your request. The Plan says the planned procedure listed under CPT code 27447 is not listed on the 
Centers for Medicare & Medicaid Services (CMS) Inpatient Only List. The Plan states the procedure is 
currently approved as an ambulatory procedure and there is no documentation provided to support the 
expectation the enrollee will require a greater than two midnight stay. The Plan states if the enrollee 
experiences ANY peri- or post-operative complications, reconsideration for inpatient level of care can be 
performed on concurrent review with updated clinical information. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee is medically stable and has been provided medical clearance to undergo 
this elective procedure. The planned procedure listed under CPT codes 27447 is not listed on the CMS 
Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no 
documentation provided to support the expectation the enrollee will require a greater than two midnight stay. 
The review has determined that the record did not show that the inpatient hospital care is 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital care following the surgery (27447).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and laboratory services provided on October 
05, 2022. 
 
You asked the Plan to pay for the office visit and laboratory services. You say that you went to the closest 
facility since your PCP was not available. The Plan denied your request. The Plan says that unauthorized, out-
of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit and 
laboratory services provided on October 05, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization. 
 
You asked the Plan to pre-approve revascularization. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that the PTA is covered when specific 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 revascularization. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found guidelines for peripheral 
revascularization are not met. In summary, there is insufficient documentation to support the medical necessity 
for peripheral revascularization in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revascularization have not been met. Therefore, we decided that the Plan does 
not have to pre-approve revascularization.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) cervical spine 
without contrast (72141), and magnetic resonance imaging (MRI) thoracic without contrast (72146). 
 
You asked the Plan to pre-approve an MRI cervical without contrast, and an MRI thoracic without contrast. 
You say that the services are medically necessary. The Plan denied your request. The Plan says the services are 
not medically necessary. 
 
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 an MRI cervical without contrast, and 
an MRI thoracic without contrast. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found there is no medical need for a cervical and thoracic MRI. There are no clinical 
symptoms of myelopathy or cord dysfunction documented. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI cervical without contrast, and an MRI thoracic without contrast have 
not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging 
(MRI) cervical spine without contrast (72141), and magnetic resonance imaging (MRI) thoracic without 
contrast (72146).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary for the 
enrollee to receive the therapy needed during their recovery. The Plan denied your request. The Plan says the 
enrollee can stay in the hospital until they are safe for transfer or discharge. 
 
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 the enrollee appears to be improving with current treatment but is still somewhat 
unstable and should only require short term additional acute care services that can safely be provided at the 
current facility until more appropriate for a lower level of care. The enrollee does not require services at the 
LTACH that are not already available at the current facility. 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: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve crowns (D2740) and core buildup (D2950) for tooth #21 and 
#22. We decided that the Plan does not have to pre-approve pulp debridement (D3221), and surgical 
procedures (D3910) for tooth #21 and #22.  
 
You asked the Plan to pre-approve crowns (D2740), core buildup (D2950), pulp debridement (D3221), and 
surgical procedures (D3910) for tooth #21 and #22.. You say that the requested dental services are medically 
necessary. The Plan says that the x-rays do not show a root canal was done; therefore, the crowns and core 
buildup criteria were not met. Also, the denial of authorization for the pulp debridement and surgical 
procedures is correct, because they are not covered by the Plan. 
 
We decided that the Plan has to pre-approve crowns (D2740) and core buildup (D2950) for tooth #21 and 
#22.  
 
The Plan follows Medicare rules. Medicare rules say that 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. 
 
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 dental services. Our reviewer says 
that the crowns and core buildup for teeth #21 and #22 are medically necessary. Our physician reviewer found 
that the documentation indicates that teeth #21 and #22 appear to have significant coronal breakdown due to 
caries or fracture to warrant core buildup and crown restorations to provide adequate masticatory function.  
 
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 dental services have been met. Therefore, we decided that the Plan has to 
pre-approve crowns (D2740) and core buildup (D2950) for tooth #21 and #22.  
 
We also decided that the Plan does not have to pre-approve pulp debridement (D3221), and surgical 
procedures (D3910) for tooth #21 and #22. 
 
The Plan follows Medicare rules. Medicare rules say that 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, the surgical procedure is not among 
those covered under this benefit. Pulp debridement is only covered by the Plan when the enrollee's age is 
between 0 to 20. Therefore, we decided that the Plan does not have to pre-approve pulp debridement (D3221), 
and surgical procedures (D3910) for tooth #21 and #22. 
 
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 an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313) and an expandable controller 
(E2377). 
 
You asked the Plan to pre-approve the items. You say that the items are medically necessary. The Plan denied 
your request. The Plan says the items are not 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 items. Our physician reviewer 
found the request is not medically necessary as the enrollee has adequate upper body strength to manage 
standard switches on a power wheelchair. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an electronic connection between wheelchair controller and two or more power seating system 
motors (E2311), a harness (E2313) and an expandable controller (E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a safety belt and left- and right-elbow blocks for a 
power wheelchair. 
 
You asked the Plan to pre-approve a safety belt and elbow blocks. You say that the requested items are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested items duplicate 
the function of items already provided. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has been approved for a power wheelchair that includes a safety belt. The 
enrollee has also been approved for a power tilt and recline system for the power wheelchair that includes 
adjustable arm rests. The items already approved for coverage serve the same purpose as a safety belt and left- and right-elbow blocks. Therefore, we decided that the Plan does not have to pre-approve a safety belt and left- 
and right-elbow blocks for a power wheelchair.
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 services are necessary for the enrollee to get back 
to prior level of functioning. The Plan denied your request. The Plan says the services can be received 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 the enrollee does not require treatment by multiple therapies. The enrollee has had a 
decline from their baseline level of function and would benefit from therapy. The enrollee does not require the 
intensity of therapies provided at an acute inpatient rehabilitation. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150-91, 87481, 87653, 87798-91, and 
87641-91 billed for date of service April 26, 2022. 
 
You asked the Plan to pay for procedure codes 87150-91, 87481, 87653, 87798-91, and 87641-91. The Plan 
denied your request. The Plan says the payment for the codes is bundled into payment for other services. 
 
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 87150-91 is a column II code to column I code 87500. Code 87481 is 
a column II code to column I codes 87150 and 87801. Code 87653 is a column II code to column I codes 87150 
and 87801. Code 87798-91 is a column II code to column I codes 87150 and 87801. Code 87641-91 is a 
column II code to column I codes 87150 and 87801. The codes at issue have 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 procedure codes 87150-91, 87481, 87653, 
87798-91, and 87641-91 billed for date of service April 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Mvasi (Q5107). 
 
You asked the Plan to pre-approve Mvasi. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested drug has been prescribed for an off-label 
and not medically accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Mvasi. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
requested use of Mvasi is not FDA-approved for the enrollees diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Mvasi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Mvasi (Q5107).