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

 
We decided that the Plan does not have to pre-approve orthopedic footwear, ladies shoes (L3216). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not covered under your contractual policy 
or by Medicare for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthopedic footwear) are only covered for 
patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
 
 
 
 
 
 
 Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthopedic footwear may be appropriate for you, neither Medicare nor the Plan provides coverage of these 
items for your condition. Additionally, with the exception of the situations described above, orthopedic 
footwear billed using code L3216 will be denied as non-covered Therefore, we decided that the Plan does not 
have to pre-approve orthopedic footwear, ladies shoes (L3216).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 1, 2022, 
through March 31, 2022. 
 
You asked the Plan to pay for the home health services. You say that this was processed as out-of-network, and 
you feel that you are in-network with the Plan. The Plan denied your request. The Plan says this claim was not 
billed with an allowed TOB. 
 
The Plan must follow Medicare rules. Medicare rules say that the covered TOBs for a final claim for home 
health services are 0327, 0328, or 0329. 
 
We looked at the file and Medicare rules. This claim was billed with TOB 0323. Based on this information, we 
decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided from March 1, 2022, through March 
31, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve an anterior cervical discectomy and fusion with allograft. 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has persistent neck pain. She 
reports the axial neck pain increased with activity or strain. The pain extends outward into her bilateral 
shoulders with numbness and tingling of her hands from the wrists through the tips of her fingers that typically 
occurs at nighttime. The exam reveals intact sensation, strength, and reflexes of the bilateral upper extremities. 
Provided documentation demonstrates subjective and objective deficits that are corroborated by imaging 
studies. Trial and failure of conservative treatment modalities have been documented. Therefore, the requested 
anterior cervical discectomy and fusion with allograft at C5-7, in this case, is medically 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve an anterior cervical discectomy and fusion with allograft.  
 
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 a group 3 power wheelchair with accessories. 
 
You asked the Plan to pre-approve group 3 power wheelchair. You say that the enrollee does not have the 
strength to ambulate. The Plan denied your request. The Plan says Medicare does not cover this durable 
medical equipment in a skilled nursing location. 
 
The Plan must follow Medicare rules. Medicare rules say that separate payment is not made for rental or 
purchase of DME when an enrollee is a patient in an institution such as a skilled nursing facility.  
 
We looked at the file and Medicare rules. The enrollee is a patient in a skilled nursing facility (SNF); therefore, 
the requested power wheelchair and accessories are not separately covered. Based on this information, we 
decided that Medicare rules for coverage of group 3 power wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair with accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for car wheelchair carrier (E1399) and the unlisted supplies and 
materials (99070) purchased December 24, 2021. 
 
You asked the Plan to pay for the car wheelchair carrier. You say that you needed a wheelchair carrier for your 
car because the wheelchair and you sister will not fit i the car at the same time. Obviously if your sister needs a 
wheelchair, you must have some way to transport both her and the wheelchair. The Plan denied your request. 
The Plan says this item does not meet the definition of DME, is not for home use and does not serve a medical 
purpose. 
 
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 pay for car wheelchair carrier (E1399) and the unlisted supplies and 
materials (99070) purchased December 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81455 billed for date of service March 4, 
2022. 
 
You asked the Plan to pay for procedure code 81455. You say that this testing was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this test was billed with a code 
which is considered not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that certain codes are automatically denied as not 
medically necessary as they are unlikely to impact therapeutic decision making in the clinical management of a 
patient.  
 
We looked at the file and Medicare rules. Code 81455 was listed under the Group 3 Paragraph of Article 
A56199 at the time of services. This means that this service is considered automatically denied as not 
medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure code 81455 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 81455 
billed for date of service March 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Camzyos. 
 
You asked the Plan to pre-approve Camzyos. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not a covered 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 Camzyos.  
 
Benefits for Camzyos 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic activities (97530) billed for date of service July 
14, 2021. 
 
You asked the Plan to pay for therapeutic activities. You say that these services were medically necessary and 
were billed correctly. The Plan denied your request. The Plan says these services are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that this service is not supported in the medical record. Specifically, the documentation shows that this 
claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by an Occupational 
Therapist. There is no indication that the Nurse Practitioner was present on site while the therapy services were 
being rendered. The incident-to requirements have not been met in this case. Based on this information, we 
decided that Medicare rules for coverage of therapeutic activities have not been met. Therefore, we decided that 
the Plan does not have to pay for therapeutic activities (97530) billed for date of service July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00832) provided on June 10, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed 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. 
 
We find that CPT code 00832 is not supported in the medical record. Specifically, no anesthesia log was 
included in the records provided. Based on this information, we decided that Medicare rules for coverage of the 
anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia 
services (00832) provided on June 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds the Medicare 
criteria for LTACH admission. The Plan denied your request. The Plan says that Medicare guidelines for 
LTACH admission were not met and the enrollee can receive the care they need in another setting like a skilled 
nursing facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting.  
 
  There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The health plan has approved ongoing care in the current acute care 
setting.  
 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (64633, 64634). 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that this is medically necessary. The Plan 
denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the thermal radiofrequency destruction of 
cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically 
reasonable and necessary for patients who have had at least two (2) medically reasonable and necessary 
diagnostic medial branch blocks (MMBs), with each one providing a consistent minimum of 80% sustained 
relief of primary (index) pain (with the duration of relief being consistent with the agent used).  
 
We looked at the file and Medicare rules. The submitted medical records do not document the performance or 
results of two MBBs. Based on this information, we decided that Medicare rules for coverage of 
radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
radiofrequency ablation (64633, 64634).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mental health outpatient services to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve mental health outpatient services. The Plan denied your request. The Plan 
says a Single Case Agreements (SCA) can be approved when there are no in-network providers who can meet 
your treatment needs. An SCA can also be approved if changing providers would harm you. We have qualified 
in-network providers who can treat you for anxiety, depression, schizophrenia, and trauma. They have open 
appointments. We have not received information showing that changing providers would hurt your health or 
safety.  
 
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 these services. Therefore, we decided that the Plan does not have to pre-approve mental 
health outpatient services to be provided by an out-of-network 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 LTACH is medically necessary for the 
member's care. You also say that the member meets the LTACH criteria for placement. The Plan denied your 
request. The Plan says the member is receiving appropriate in-patient acute care and is currently unstable for 
transfer to an LTACH. 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you have an appointment with this 
provider on October 25, 20222. The Plan denied your request. The Plan says the office you are requesting said 
that they will not accept your Medicare Advantage (HMO) authorization and will not see 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 the office 
services to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says according to the 
information reviewed the requested service is not medically necessary. 
 
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 was admitted for elective knee replacement surgery. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. While the enrollee has a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for five units of code 88374-26 provided on date of service 
March 22, 2022. 
 
You asked the Plan to pay for five units of code 88374-26. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. The Plan stated that they called you and you confirmed that only 5 total units 
of this code were provided, and 5 units have been paid. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 4, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for five units of code 88374-26 have not been met. Therefore, we decided that the Plan does not have to pay for five units of code 88374-26 provided on date 
of service March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (E1399). 
 
You asked the Plan to pre-approve the power scooter. You say that the power scooter is medically necessary. 
The Plan denied your request. The Plan says the scooter is primarily for use outside the home and is not 
covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 
 
 
 
 
 
 
 The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary for the enrollee to receive 
IRF care. The Plan denied your request. The Plan says that the criteria for IRF admission were not met, and the 
enrollee can receive the care they need in a lower-level setting like a skilled nursing facility. 
 
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 enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for bleeding from an AV fistula. Medical problems are stable. There are no complex 
nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this 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 IRF admission and services.