Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 visits of physical therapy services. 
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee has an onset of severe low 
back pain and muscle spasm.  The Plan denied your request. The Plan says the 14 physical therapy visits 
requested do not meet the requirements for approval.  
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested therapy is not medically necessary. The plan of care has 
not been certified by a physician or non-physician practitioner (who works under the guidance of or with a 
physician). 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 14 visits of physical therapy services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that a SNF admission is medically necessary. The Plan 
denied your request. The Plan says the SNF level of care is not medically necessary. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is a 91-year-old female with a medical history including hypertension, 
cardiac disease, atrial fibrillation, diabetes mellitus, previous hip replacement and previous compression 
fracture who was admitted to the hospital after a mechanical fall from a wheelchair. The documentation 
indicates she has remained medically stable and did not suffer a significant injury. The most recent therapy 
documentation indicates the enrollee is at or near her baseline level of function. She is able to ambulate 45 feet 
using a walker with minimal assistance. 
 
The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically 
stable and can receive further therapy services at a lower level of care.  Although further therapy services 
would be appropriate to improve function, as a practical matter, the intermittent skilled services can be 
provided at a lower level of care than a skilled nursing 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99203) provided on January 5, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit . You say that please review the report for medical necessity. The 
Plan denied your request. The Plan says enrollees must receive their medical services from an in-network 
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 
providers require prior authorization before services being rendered. 
 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 the outpatient office visit (99203) provided on 
January 5, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Nitro rollator walker (E1399). 
 
You asked the Plan to pre-approve a walker. You say that the requested items/services are not considered 
medically reasonable and necessary in this case. The Plan denied your request. The Plan says  the records do 
not show that the walker (Nitro walker / rollator) is on the preferred list. 
 
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 walker. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation is not clear that the enrollee has a mobility limitation that significantly 
impairs their ability to participate in one or more mobility-related activities of daily living (MRADL) in the 
home. The documentation does not support that a standard walker will not be safe or effective for the enrollee. 
The request for the Nitro rollator walker is not medically necessary per Local Coverage Determination (LCD) 
Walkers L33791 and  Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), as Medicare does 
not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness 
or injury or to improve the functioning of a malformed body 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 a walker have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Nitro rollator walker (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vasectomy (55250) provided on September 30, 2022. 
 
You asked the Plan to pay for the surgical service. You say that you asked your doctor if they could perform 
this surgery. You also say that you have never had a claim deny before. The Plan denied your request. The Plan 
says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgical service have not been met. Therefore, we decided that the Plan does not have to pay 
for the vasectomy (55250) provided on September 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary.  The Plan denied your request. The Plan says the enrollee does not meet criteria for a home 
ventilator. 
 
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. 
 
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 home ventilator. Our reviewer says that the enrollee does not meet criteria for a home ventilator. Our physician reviewer found the record indicates 
that the enrollee has chronic hypoxic and hypercarbic respiratory failure from chronic obstructive pulmonary 
disease. The record indicates that the enrollee is being treated with bilevel positive airway pressure (BiPAP).  
The provided primary source documentation does not contain sufficient detailed information in the medical 
record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with average 
volume-assured pressure support (AVAPS) capability and failure of such a device has not been documented.  
The elements of the coverage criteria are not satisfied.  The requested service cannot be 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bioventus Signafuse (20930). 
 
You asked the Plan to pre-approve Bioventus Signafuse. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan 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 Bioventus Signafuse. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found signafuse graft is experimental. More research is needed. Iliac crest bone graft is the 
gold standard. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Bioventus Signafuse have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Bioventus Signafuse (20930).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (tilt, recline, leg elevation) and related accessories.  
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that these items are medically 
necessary. The Plan denied your request. The Plan says that the requested power wheelchair and accessories 
are not medically necessary. 
 
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 a power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that the enrollee 
does not have skin breakdown, does not use a catheter, and does not have spasticity that interferes with 
positioning. As the power wheelchair is base is not medically necessary, the requested accessories are 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 a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power options (tilt, 
recline, leg elevation) and related accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 19, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 23 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the pain in your left knee is really high 
when you move around. The Plan denied your request. The Plan says you have received over 60 sessions of 
therapy with minimal improvement in your function. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the records do not demonstrate that the unique skills of a professional 
therapist are required to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or by - or under - the supervision of a therapist. The requested services are not 
part of a maintenance 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 23 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Ottobock Kenevo knee. 
 
You asked the Plan to pre-approve a Ottobock Kenevo knee. You say that the enrollee's current socket no 
longer matches the contours of the residual limb. You say that the enrollee needs to upgrade to a K3 knee. You 
also say that the liners and socks are worn. The Plan denied your request. The Plan says the notes do not 
support that the enrollee is a K3 ambulator. 
 
The Plan follows Medicare rules. Medicare rules say that a fluid, pneumatic, or electronic/microprocessor knee 
is covered for beneficiaries whose functional level is 3 or above. 
 
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 Ottobock Kenevo knee. Our reviewer 
says that the request for Ottobock Kenevo knee is not medically necessary. Our physician reviewer found the 
documentation does not support that you are able to ambulate at a K3-functional level. There is no 
documentation to support that you require an upgraded, K3-functional level knee. Therefore, the reviewer 
found that the request for a Ottobock Kenevo knee is not medically reasonable or 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 a Ottobock Kenevo knee have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Ottobock Kenevo knee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Via disc NP (0627T). 
 
You asked the Plan to pre-approve Via disc NP. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
The Plan 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 Via disc NP. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Via disc NP allograft is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Via disc NP have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Via disc NP (0627T).
Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 95999. We decided that the 
Plan does not have to pay for the services described by procedure code(s) 95861-26 and 95861-26-XU.  
 
You asked the Plan to pay for testing services provided on May 17, 2022, billed with codes 95999, 95861-26 
and 95861-26-XU. You say that the claim was billed correctly and should be paid. The Plan says that the 
number of units billed exceeds the maximum allowed.  
 
We decided that the Plan has to pay for the services described by procedure code(s) 95999.  
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 95999.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
95861-26 and 95861-26-XU. 
 
The Plan follows Medicare rules. Medicare rules say that submitted claims in which the unit of service exceeds 
the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess units.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services described by procedure code(s) 95861-26 and 95861-26-XU have not been met. In this 
case, the MUE for CPT code 95861 is 1. The MAI value for this code is 3. You billed 2 units of this code, 
exceeding the MUE. You did not provide all the required evidence showing that the excess units were actually 
provided, were correctly coded, and were medically necessary.  Therefore, we decided that the Plan does not 
have to pay for the services described by procedure code(s) 95861-26 and 95861-26-XU. 
 
 
 
 
 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided by a Licensed 
Marriage and Family Therapist (LMFT) from August 18, 2022, to November 3, 2022. 
 
You asked the Plan to pay for the LMFT services. You say that although the provider cannot participate in 
Medicare, you still believe that the Plan should pay for these services. The Plan denied your request. The Plan 
says services provided by a LMFT are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the only provider types eligible to provide 
Medicare-covered mental health services are as follows: Physicians, Clinical Psychologists, Clinical Social 
Workers, Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists.  
 
 The provider at issue in this appeal is a LMFT, which is not a valid provider type to bill Medicare patients.  
The enrollee is a Medicare Advantage member, meaning that all Medicare billing rules apply. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the LMFT services have not been met. Therefore, we decided that the Plan does not have to pay for 
outpatient mental health services provided by a Licensed Marriage and Family Therapist (LMFT) from August 
18, 2022, to November 3, 2022.