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

 
We decided that the Plan does not have to pre-approve a flex walk system (L5981). 
 
You asked the Plan to pre-approve a flex walk system. You say that this item is medically necessary. The Plan 
denied your request. The Plan says this item is not medically necessary. 
 
The Plan follows 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. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 flex walk system. Our reviewer says 
that this item is not medically necessary. Our physician reviewer found the documentation does not reveal 
evidence to corroborate the vendor (prosthetist) claims that the patient is a K3 ambulator. The documentation 
does not support that the patient's current functional needs require a K3 level foot. 
 
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 flex walk system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a flex walk system (L5981).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital stay provided on July 13, 2022. 
 
You asked the Plan to pay for inpatient hospital stay. You say that you are requesting reconsideration. 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 inpatient hospital stay 
provided on July 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and appliance 
(E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. 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. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and appliance (E0667).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from September 12, 2021, 
to September 20, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that in addition to reporting a visit line using the G codes, 
HHAs must report an additional line item with the same revenue code and date of service, reporting one of the 
three Q codes (Q5001, Q5002, and Q5009), one unit and a nominal covered charge. 
 
We looked at the file and Medicare rules. The file shows that the home health claim was not billed with one of 
the required Q codes. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from September 12, 2021, to September 20, 2021.
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 a lower level of care is not safe, sufficient, or 
equipped to address the needs related to the enrollee's comorbidity and allow opportunity to regain prior level 
of functioning to improve quality of life. The Plan denied your request. The Plan says medically necessary care 
may be provided safely in a different 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 there are no documented active medical issues with the complexity of the enrollee's 
documented nursing, medical and rehabilitation needs 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed with rail and mattress. 
 
You asked the Plan to pre-approve a total electric hospital bed with rail and mattress. You say that you have 
sciatica, lower back pain, arthritis in your knee, cellutitis in both legs. You also say that your limbs need to be 
elevated while you sleep without affecting your back or neck. The Plan denied your request. The Plan says the 
requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed with rail and mattress.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic office visit provided on August 29, 2022. 
 
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the chiropractic office visit provided on August 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in shower. 
 
You asked the Plan to pre-approve a walk-in shower. You say that please reconsider and see the necessity for 
the prescription written by your doctor for wellness purposes. The Plan denied your request. The Plan says this 
item is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in shower.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for infectious-agent testing (87506) billed for date of service July 26, 2022. 
 
You asked the Plan to pay for infectious-agent testing. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says that the services at issue have been billed with an 
incorrect CPT code. 
 
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. Specifically, the Plan has not provided laboratory results by which to determine 
what was tested and whether the CPT code billed is correct. It is the Plan's responsibility to substantiate its 
denial with evidence. In this case, the Plan's denial has not been substantiated, so we must find in your favor. 
Therefore, we decided that the Plan has to pay for infectious-agent testing (87506) billed for date of service 
July 26, 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 pre-approve a Myomo arm brace (L8702). 
 
You asked the Plan to pre-approve a Myomo orthosis. You say that the device is medically necessary. The Plan 
denied your request. The Plan says this decision was made using the enrollee's benefit documents, the Plan's 
guidelines for medical necessity, experimental and investigational services, and the local coverage practices. 
 
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 Myomo arm brace. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro orthosis is not known to be effective, based on scientific evidence, 
professional standards, and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for this enrollee's condition or in widespread use for this enrollee's condition based on scientific evidence. 
There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes 
for this enrollee. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 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 Myomo orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Myomo arm brace (L8702).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from July 22, 
2020, to July 31, 2020. 
 
You asked the Plan to pay for SNF care. You say that these services are supported in the medical record. The 
Plan denied your request. The Plan says specific supporting documents must be submitted to support these 
services as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. The rules also say that providers must report SNF services with the 
appropriate HIPPS code, which is also supported by the medical records and includes the Minimum Data Set 
(MDS) Version 3.0, the Care Area Assessment (CAA) process and the RAI Utilization Guidelines. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of SNF care have been met. Specifically, 
the records provided do not include a complete MDS form. Entire sections of this necessary form are missing, 
and some sections are incomplete. Therefore, we decided that the Plan does not have to pay for skilled nursing 
facility (SNF) care provided from July 22, 2020, to July 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Opioid treatment program services provided on July 5, 2022. 
 
You asked the Plan to pay for Opioid treatment program services. The Plan denied your request. The Plan says 
the services were rendered by a provider who is credentialed as a Registered Nurse and is non-participating 
with the Plan's network. 
 
The Plan must follow Medicare rules. Medicare rules say that a Registered Nurse is not eligible to participate in 
the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Registered Nurse. Medicare 
says that a Registered Nurse is not eligible to participate in the Medicare program. Therefore, we decided that 
the Plan does not have to pay for Opioid treatment program services provided on July 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the low dose computed tomography (LDCT) scan for lung 
cancer screening (71271) provided on August 1, 2022. 
 You asked the Plan to pay for the LDCT scan. You say that this service was medically necessary and 
appropriate for this enrollee. The Plan denied your request. The Plan says the records do not show that the 
enrollee has met all of the necessary criteria for coverage of an LDCT scan. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the provided records do not indicate that the enrollee 
is a current smoker or former smoker who quit within the last fifteen years with a minimum 20 pack-year 
smoking history. Therefore, we decided that the Plan does not have to pay for the low dose computed 
tomography (LDCT) scan for lung cancer screening (71271) provided on August 1, 2022.
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 enrollee needs LTACH due to 
requiring antibiotics every 4 hours a lower level of care will not provide this due to cost. The Plan denied your 
request. The Plan says it is not safe for the enrollee to transfer at this time and is receiving the care needed in 
the current hospital. 
 
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 health 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: 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. You say that the enrollee is not able to walk on their own and 
needs strength training and therapy. You say the enrollee's care team thinks the therapy will be beneficial. The 
Plan denied your request. The Plan says based on Medicare guidelines, the IRF services requested 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for EVENITY (romosozumab-aqqg), 1 mg 
injections provided from January 24, 2022 to July 6, 2022. 
 
You asked the Plan to waive the coinsurance for EVENITY (romosozumab-aqqg), 1 mg injections. You say 
that the doctor confirmed, in January 2022, that there would be no charges and nothing was mentioned to you 
until July 2022 when the doctor stated she would not see you until the bill was paid off. You say that you were 
not made aware of the copayment by the doctor or by the insurance Plan. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for EVENITY (romosozumab-aqqg), 1 mg injections. This 
service falls within the Medicare Part B prescription drugs benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for EVENITY (romosozumab-aqqg), 1 mg injections provided from  
January 24, 2022 to July 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve a seat lift mechanism. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 a seat lift mechanism. Our reviewer 
says that the documentation does not support that the requested device is medically reasonable or necessary. 
Our physician reviewer found the medical records (one telemedicine visit dated December 20, 2022) document 
neuromuscular weakness due to Parkinson's disease. The provided medical records do not document the seat 
lift is included in the treating practitioner's course of treatment. The documentation does not support that the 
enrollee is completely incapable of standing from a chair in the home. Therefore, the enrollee does not meet 
criteria for the requested device. 
 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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Prolotherapy provided on April 22, 2022. 
 
You asked the Plan to pay for Prolotherapy. The Plan denied your request. The Plan says this provider is not 
enrolled in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Prolotherapy have not been met. Therefore, we decided that the Plan does not have to pay for 
Prolotherapy provided on April 22, 2022.