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

 
We decided that the Plan does not have to pre-approve a motorized scooter. 
 
You asked the Plan to pre-approve a motorized scooter. The Plan denied your request. The Plan says you do 
not meet the Medicare guidelines for a motorized 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 a motorized scooter. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found you are noted to have normal 
gait and stance. You do have a history of falling and a bariatric walker was recommended and ordered. Our 
reviewer found that you are noted to have difficulty with community mobility but have a manual wheelchair for 
mobility and caregiver assistance if needed. Our physician reviewer also found that there is no documentation 
as to if you can safely operate the requested group 1 power mobility device and if your 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 a motorized scooter have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a motorized 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 you say that you disagree with the denial for the 
admission to an IRF for the enrollee. The Plan denied your request. The Plan says the required 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 enrollees nursing medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical and rehabilitation needs do not require the intensive interdisciplinary approach provided on acute 
inpatient rehabilitation. The enrollee does not require treatment by multiple therapies. The enrollee may benefit 
from therapy and assistance, but they does not require the intensity of therapies provided on acute inpatient 
rehabilitation. Therefore, the acute inpatient rehabilitation admission is not 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 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
June 22, 2023. 
 
You asked the Plan to pay for procedure codes 20930 and 20936. You say that the medical records support the 
billing of these codes. The Plan denied your request. The Plan says procedure codes 20930 and 20936 are 
considered bundled and not separately payable.  
 
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 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 20930 and 20936 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 20930 and 20936 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
June 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral surgery consultation (99203). 
 
You asked the Plan to pre-approve an oral surgery consultation. You say that this service should be covered. 
The Plan denied your request. The Plan says the medical services of physicians, including an oral surgeon 
consultation, in connection with the non-covered dental service are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that 
are not covered or paid for by Medicare. Specifically, the services in dispute are for physician services that will 
be furnished in connection with dental extractions that are not being done to prepare the jaw for radiation 
treatment. Therefore, we decided that the Plan does not have to pre-approve an oral surgery consultation 
(99203).
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 needs this level of care. The Plan denied 
your request. The Plan says medical records do not support the need for an IRF admission and, the enrollee 
needs can be provided at another 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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. 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. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve blepharoplasty, upper eyelid; with excessive skin 
weighting down lid (15823). 
 
You asked the Plan to pre-approve blepharoplasty, upper eyelid; with excessive skin weighting down lid 
(15823). You say that you are appealing with supporting records. The Plan denied your request. The Plan says 
this 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 pre-approve blepharoplasty, upper eyelid; with 
excessive skin weighting down lid (15823). Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the 
visual fields do not demonstrate 15 degree or 30% superior field loss that improves with taping. Our physician 
reviewer also says that the enrollee does not meet the criteria for a blepharoplasty, upper eyelid; with excessive 
skin weighing down the lid. Our physician reviewer also found that blepharoplasty and surgical procedures of 
the brow performed for the sole purpose of improving appearances are considered not 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 blepharoplasty, upper eyelid; with excessive skin weighting down lid (15823) 
have not been met. Therefore, we decided that the Plan does not have to pre-approve blepharoplasty, upper 
eyelid; with excessive skin weighting down lid (15823).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda, Abraxane and carboplatin. 
 
You asked the Plan to pre-approve the drugs. You say that the enrollee has started on treatment with 
carboplatin and paclitaxel, however the enrollee has developed severe nephropathy after anti HER2 treatments 
which significantly impacting their quality of life. The Plan denied your request. The Plan says that Keytruda, 
Abraxane and Carboplatin are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drugs. Our reviewer says that 
Keytruda, Abraxane and carboplatin is medically necessary. Our physician reviewer found that that the 
requested use of Keytruda, Abraxane and carboplatin is supported by one of the major drug compendia and by 
clinical research. Keytruda, Abraxane and carboplatin is also safe and effective and otherwise reasonable and 
necessary for the enrollee. The LCD coverage criteria has been met. 
 
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 drugs have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda, Abraxane and carboplatin.  
 
  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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 6, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from November 6, 2023, forward. You say that 
the services at issue were medically necessary. The Plan denied your request. The Plan says the services at 
issue were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from 
November 6, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an 
acute inpatient mental health treatment beyond the date in question of November 6, 2023, forward. Our 
physician reviewer found the enrollee did not require inpatient mental health treatment beyond November 6, 
2023, as he was not a danger to himself or others and did not have any delusions, auditory or visual 
hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not 
appear that the services for the dates in question were reasonably expected or medically necessary to improve 
the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from November 6, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 6, 
2023, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power option and additional items and accessories (codes E0955, E1007, E1012, E1028, E2311, E2313, E2361, 
E2377, E2607, and E2620). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and additional items and accessories. 
You say that the enrollee meets the requirements for a K0861 Group 3 power wheelchair with power tilt and 
recline as requested in the original Authorization Request. You also say that the enrollee has a mobility 
limitation caused by Multiple Sclerosis which is a neurological condition and is unable to perform independent 
pressure relief, leaving them at risk of developing pressure ulcers and infections. The Plan denied your request. 
The Plan says the enrollee does not have medical need for multiple power options included with a K0861 group 
3 power wheelchair. The Plan also says the electronic connection, harness, and expandable controller cannot be 
covered as it is not medically necessary to control the three requested power options through the joystick (drive 
interface). 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
 
  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 Group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found the enrollee has multiple sclerosis (MS) and is able to ambulate short distances. The 
enrollee has long standing functional loss, intact skin, and is able to feed themself. Our reviewer also found that 
the enrollee does not have high risk for skin breakdown, use a catheter intermittently, have spasticity or require 
an alternative means of managing power drive. 
 
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 Group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 standard power 
wheelchair with multiple power option and additional items and accessories (codes E0955, E1007, E1012, 
E1028, E2311, E2313, E2361, E2377, E2607, and E2620).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the pelvis. 
 
You asked the Plan to pre-approve an MRI of the pelvis. The Plan denied your request. The Plan says an MRI 
of the pelvis is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of the pelvis. Our reviewer says 
that an MRI of the pelvis is not medically necessary. Our physician reviewer found that there was insufficient 
support made for the MRI of the pelvis as there was no objective findings directly related to the pelvis or hips, 
failure of conservative treatments for the pain, or a red flag diagnosis warranting early consideration for pelvic 
advanced imaging. Also, recent imaging of the pelvis and hip area a few days prior did not reveal any acute 
findings in the pelvis or hips but did show chronic degenerative changes of the hip joints. Therefore, the 
request for the MRI of the pelvis will be considered not 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 an MRI of the pelvis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an MRI of the pelvis.
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 needs this level of care. The Plan denied 
your request. The Plan says medical records do not support the need for an IRF admission and, the enrollee 
needs can be safely provided at another 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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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. 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 inpatient rehabilitation facility (IRF) admission and services.
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 services are medically necessary. The Plan 
denied your request. The Plan says your medical needs can be met at an alternate 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 you do not require treatment by multiple therapies. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29125 billed for date of service November 
24, 2022.  
 You asked the Plan to pay for procedure code 29125. You say that the enrollee had injuries to both arms. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 29125 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. You billed one line item of this code with the LT modifier and one line item of this 
code with the RT modifier instead of billing one line item with the bilateral modifier as is required. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 29125 billed for date of service November 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee brace (L1852) and suspension sleeve (L2397), 
provided on June 26, 2023. 
 
You asked the Plan to pay for a knee brace and suspension sleeve. You say that the items should be covered. 
The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. There is no indication this item was needed or ordered in the medical records submitted. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for a knee brace (L1852) and suspension sleeve 
(L2397), provided on June 26, 2023.