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

 
We decided that the Plan does not have to pre-approve a power operated vehicle (power scooter). 
 
You asked the Plan to pre-approve power operated vehicle. You say that the enrollee has trouble completing 
activities of daily living (ADLs). The Plan denied your request. The Plan says there is no indication of the 
enrollee's ability to operate a power operated vehicle (POV), or why a walker or manual wheelchair could not 
meet the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules state that a power operated vehicle may be covered if certain 
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 power operated vehicle. Our reviewer 
says that the enrollee does not meet criteria for this device. Our physician reviewer found the documentation 
does not indicate if the enrollee can safely transfer to and from the power scooter and has the degree of trunk 
control necessary to operate it. Additionally, there is no indication that the enrollee's home is accessible. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power operated vehicle have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power operated vehicle (power scooter).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services as billed for date of service 
February 13, 2022, to March 14, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan follows Medicare rules. Medicare rules say that home health services are only covered when billed 
with appropriate Patient-Driven Groupings Model (PDGM). 
 
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 the home health services as billed. Our 
reviewer says that the documentation does not support the PDGM billed. Our physician reviewer found the 
enrollee received home health services. No OASIS form pertaining to the dates of service at issue was 
submitted. Therefore, the services are not payable as billed. 
 
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 home health services as billed have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health services as billed for date of service February 13, 2022, 
to March 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) testing provided 
on May 17, 2023. 
 
You asked the Plan to pay for the urine PCR testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services provided were 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 the urine PCR testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the urine PCR testing was considered excessive. Therefore, the enrollee did not meet 
criteria for the services rendered. 
 
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 urine PCR testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the urine polymerase chain reaction (PCR) testing provided on May 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you are appealing this denial. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
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 these services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says these services can be provided in an alternate setting.  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies. 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 the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vest Airway Clearance System (E0483). 
 
You asked the Plan to pre-approve a Vest Airway Clearance System. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a HFCWO device is covered when the criteria 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 Vest Airway Clearance System. Our 
reviewer says that this device is not medically necessary. Our physician reviewer found that the enrollee has 
severe COPD with hyperinflation. There is no diagnosis of bronchiectasis, cystic fibrosis, or neuromuscular 
disease. COPD is not a diagnosis for which Medicare covers a high-frequency chest wall oscillation device, 
because its benefit has not been established in the treatment of patients with this disease.  
 
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 Vest Airway Clearance System have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Vest Airway Clearance System (E0483).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye exam provided on January 25, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the OON eye exam. You say that office staff incorrectly verified insurance and 
thought the patient had a different type of plan under which you were covered. You say that the medical 
records provided support that the services provided were medically necessary. The Plan denied your request. 
The Plan says it was not medically necessary to receive care from an OON provider, as network providers were 
available.  
 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an eye exam provided on January 25, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99205 billed for date of service May 8, 2023. 
 
You asked the Plan to pay for procedure code 99205. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that payment for code 99205 is bundled into 
payment for codes 95886 and 95913. 
 
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 99205 
is not a column II code to codes 95886 and 95913. Based on the claim submitted, Medicare billing criteria have 
been met.  
 
The rules also say that Medicare health plans must make reasonable and diligent efforts to gather and forward 
to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable 
and diligent efforts to gather and forward to us information regarding their decision to deny your request. The 
Plan provided no evidence that these codes cannot be reported together. Therefore, we decided that the Plan has 
to pay for procedure code 99205 billed for date of service May 8, 2023.  
 
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 placement of the SPRINT PNS System. 
 
You asked the Plan to pre-approve placement of the SPRINT PNS System. You say that the service is 
medically necessary. The Plan denied your request. The Plan says this is considered experimental. 
 
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 placement of the SPRINT PNS System. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of placement of the SPRINT PNS System have not been met. Therefore, we 
decided that the Plan does not have to pre-approve placement of the SPRINT PNS System.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 26, 2023, to 
February 27, 2023, billed with evaluation and management (EM) code 99233. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the level of care is not supported. 
 
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, the CPT Code Manual definition of code 99223 is Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded. 
 We asked our physician 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 the practitioner services provided. Our reviewer says that 
the level of care is not supported. Our reviewer found documentation supports an appropriate exam, but not an 
appropriate history or medical decision making of high level. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on February 26, 2023, to February 27, 2023, 
billed with evaluation and management (EM) code 99233.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve lower limb prosthetic components (L5828, L5845, L5850, L5925, 
L5981, L5986). 
 
You asked the Plan to pre-approve lower limb prosthetic components. You say that you desperately need a 
prosthetic leg with advanced knee and foot. The Plan denied your request. The Plan says that the requested 
prosthetic parts exceed your needs. 
 
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 lower limb prosthetic components. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the medical record goes above and beyond in satisfying Medicare policy by 
demonstrating you have a long history of functioning at a K3 level and have specific needs for the requested 
components. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lower limb prosthetic components have been met. Therefore, we decided that 
the Plan has to pre-approve lower limb prosthetic components (L5828, L5845, L5850, L5925, L5981, L5986).  
 
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 ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee does have chronic obstructive 
pulmonary disease (COPD) and chronic respiratory failure, however, the documentation does not support the 
need for home ventilator with the data points or medical records provided. Hence, does not meet standard of 
care for home ventilator. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs cannot be met at a 
lower level of care. You say that the enrollee deserves to receive care in the safest and most appropriate level of 
care to regain their quality of life. The Plan denied your request. The Plan says an LTACH admission is not 
medically necessary.  
 
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 there is no therapeutic benefit to transfer, and there are no needs in an LTACH 
that are not met in the current setting.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (87506) provided on April 13, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
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, the CPT Code Manual definition of code 87506 is "Infectious agent detection by nucleic acid 
(DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, 
Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, 
multiple types or subtypes, 6-11 targets". 
 
We find that CPT code 87506 is not supported in the medical record. Specifically, the records do not support 6-
11 targets tested on the billed date of service. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the 
services (87506) provided on April 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (87506) provided on March 24, 2022. 
 
You asked the Plan to pay for the services.. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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, the CPT Code Manual definition of code 87506 is "Infectious agent detection by nucleic acid 
(DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, 
Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, 
multiple types or subtypes, 6-11 targets". 
 
We find that CPT code 87506 is not supported in the medical record. Specifically, the records do not show that 
6-11 targets were tested in this case. Based on this information, we decided that Medicare rules for coverage of the services. have not been met. Therefore, we decided that the Plan does not have to pay for the services 
(87506) provided on March 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81225, 81226, 81227, 81231, 81240, 81241, 
81401, 81328, and 81291 provided on May 18, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 81225, 81226, 
81227, 81231, 81240, 81241, 81401, 81328, and 81291 provided on May 18, 2023.