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

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says the durable medical equipment (DME) group feels that you cannot operate the 
power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that the 
documentation does not support that you have a power mobility deficit that impairs MRADLs in the home. 
The records do not show that your condition is not ameliorated by a walker, cane, or manual wheelchair. 
 A Periscope review indicated that the patient could walk 200 feet with a front wheel walker and was able to 
perform most ADLs without assistance other than for bathing. The documentation does not support that the 
requested wheelchair will significantly improve your ability to participate in MRADLs, and that you will use it 
in the home for MRADL participation. The documentation does not reveal  that the requested K0823  is 
medically necessary per Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medicare 
National Coverage Determinations Manual, Section 280.3(B). 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair with multiple power 
options and accessories. 
 
You asked the Plan to pre-approve Group 2 power wheelchair. You say that the enrollee requires this 
wheelchair. The Plan denied your request. The Plan says the enrollee has not completed the needed evaluation 
and does not meet criteria for a Group 2 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules state that a Group 2 power wheelchair with multiple power 
options is only covered if certain specified criteria have been 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 Group 2 power wheelchair. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested power wheelchair. Our 
physician reviewer found the enrollee's face-to-face examination on May 2, 2022 reported normal gait and 
station with no detailed description of a personal mobility deficit that impairs participation in mobility-related 
activities of daily living. As the base wheelchair does not meet coverage criteria, the requested accessories are 
also not covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Group 2 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 2 power wheelchair with multiple power options and accessories.
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. The Plan denied your request. The Plan says your 
medical needs are being met in the current acute setting. 
 
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 physician 
reviewer found that you were admitted to the acute hospital with hypoxic respiratory failure due to COVID-19 
pneumonia and pulmonary fibrosis. The record indicates that you still require acute care services. You continue 
to receive acute care services, and these have not been denied. The medical record does not indicate that you 
require services that you are not currently receiving but that would be available at the LTACH 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PrismRA proprietary lab testing (81479). 
 
You asked the Plan to pay for lab services. You say that this service is medically necessary and is reasonable in 
this case. 
 The Plan denied your request. The Plan says the requested lab testing is considered 
experimental/investigational, and therefore it is not medically 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 pay for lab services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has rheumatoid arthritis (RA) with moderate disease activity and is currently 
using etanercept. PrismRA proprietary lab testing was requested. However, this test is new and the clinical 
value and effectiveness of this test in the setting of RA have not been demonstrated in currently available 
literature at the time of this request. Therefore, without sufficient support made for expected clinical gains from 
this testing, this request for PrismRA will be considered not medically necessary at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for PrismRA proprietary lab testing (81479).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter. 
 
You asked the Plan to pre-approve a knee scooter. You say that the enrollee is highly recommended to strictly 
offloading on the affected foot and remain non weight bearing. 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 knee scooters (crutch substitutes) are not covered  
 
We looked at the file and Medicare rules. Review of the file shows that the requested item is specifically not 
covered. Based on this information, we decided that Medicare rules for coverage of a knee scooter have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a knee scooter.
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's mobility has declined. The Plan denied 
your request. The Plan says the enrollee's condition requires further treatment in the acute hospital. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital for seizures and a urinary tract infection. 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. 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 the diabetic shoes and inserts to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the diabetic shoes and inserts. You say that you are appealing the denied 
service. The Plan denied your request. The Plan says the requesting provider is an OON provider and they have 
confirmed there are in-network providers that the enrollee can receive the requested services from. 
 
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 diabetic shoes and inserts to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs increased monitoring 
and daily physician involvement that they can receive at an LTACH. The Plan denied your request. The Plan 
says the enrollee's status is unstable requiring continued acute hospital care. The enrollee is receiving medically 
necessary acute and/or critical care. The enrollee does not have clinical conditions that cannot be appropriately 
treated in the current hospital, and there are no issues for which LTACH may offer a therapeutic advantage. 
 
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 appears to be still somewhat unstable and requires short-term 
additional acute care services that can safely be administered at the current facility until more stable and 
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. 
 There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to LTACH is not medically necessary as the enrollee is not yet stable for transfer and 
as it would not be clinically advantageous. Completion of treatment at the current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: 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 needs a higher level of care 
than what a skilled nursing facility can provide. The Plan denied your request. The Plan says the enrollee's 
medical needs are being met in the current acute setting. The LTACH would add no additional services. With 
additional time in the current setting, clinical stability can be ensured such that the appropriate lower level of 
care can be determined. 
 
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 appears to be more stable and improving with current treatment and 
should only require short-term additional acute care services that can safely be administered 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. 
 There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. 
Completion of treatment at the current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular genetic testing services (81401, 81403, 
81404, 81405, 81406, 81407, 81408 and 81479) provided on December 28, 2021. 
 
You asked the Plan to pay for cardiovascular genetic testing. You say that these services were medically 
necessary and impacted the enrollee's ongoing treatment. The Plan denied your request. The Plan says this 
testing is not medically 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 pay for cardiovascular genetic testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the test in question is described as a genetic based cardiovascular risk factor 
screening test in which multiple genes are assessed using genomic DNA extracted from patient sampling. It assesses the presence of pathogenic or likely pathogenic variants in genes known to be associated with 
increased cardiac risk. It is not a diagnostic test. There is no evidence to support its role in this enrollees 
clinical management. In summary, the requested testing is not considered 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 cardiovascular genetic testing have not been met. Therefore, we decided that the 
Plan does not have to pay for cardiovascular genetic testing services (81401, 81403, 81404, 81405, 81406, 
81407, 81408 and 81479) provided on December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A9279, S9279, and S8301 billed for date of 
service January 11, 2022. 
 
You asked the Plan to pay for procedure codes A9279, S9279, and S8301. You say that you have provided 
medical records to support payment. The Plan denied your request. The Plan says the billed codes are invalid 
for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes A9279, S9279, and S8301 have a Status Indicator of I on the Physician Fee Schedule. This means that procedure codes A9279, S9279, and S8301 are not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of procedure codes A9279, S9279, and 
S8301 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes A9279, 
S9279, and S8301 billed for date of service January 11, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility admission provided by a 
participating provider. 
 
You asked the Plan to pre-approve a skilled nursing facility admission. You say that an SNF admission is 
medically necessary. The Plan denied your request. The Plan says the medical criteria for an SNF admission 
has not been met. 
 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 a skilled nursing facility admission. Our 
reviewer says that the medical criteria for a SNF admission has not been met. Our physician reviewer found the 
enrollee has had multiple falls and documented functional impairments thus would meet criteria for 
assessment/treatment by a professional therapist, however, there is no documentation to suggest that patient 
would require daily services 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 a skilled nursing facility admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a skilled nursing facility admission provided by a participating 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 00562-QZ billed for date of service 
December 7, 2021. 
 
You asked the Plan to pay for procedure code 00562-QZ. You say that the records show that two procedures 
were performed. The Plan denied your request. The Plan says payment for code 00562-QZ is bundled into 
payment for code 00560. 
 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 
00562-QZ is a column II code to column I code 00560. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 00562-QZ billed for date of 
service December 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has side effects from oral 
iron. The Plan denied your request. The Plan says tier exceptions are not available for Part B drugs. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
The file shows that the Plan has agreed to pre-approve Feraheme. However, there is not a tier exception 
available for this drug under the medical benefit.  The requested drug falls within the Medicare Part B 
prescription drugs benefit category. The cost sharing is a contractual obligation the enrollee agreed to pay when 
she enrolled in the Plan. Therefore, we decided that the Plan does not have to pre-approve a tier exception.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Durolane (J7318). 
 
You asked the Plan to pre-approve Durolane. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been 
met. 
 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 Durolane. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drugs Orthovisc, Synvisc or Synvisc-One before they will approve the requested drug, 
Durolane. There is no indication that the enrollee has tried and failed the required drugs. Based on the medical 
records provided and the Medicare-approved drug compendia, there is no indication that the Plan's required 
drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Durolane (J7318).