Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis at L5-S1. 
 
You asked the Plan to pre-approve arthrodesis. You say that the enrollee would benefit from this procedure. 
The Plan denied your request. The Plan says this is not considered 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 arthrodesis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found dynamic flexion/extension films are not provided in order to potentially assess the amount of 
movement (instability) at the requested surgical level. Detailed documentation is not evident regarding 
potential impending/inevitable temporary intra-operative instability. No compelling rationale is presented, or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested arthrodesis L5-S1 bilaterally with SurGenTec Ion facet screws 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 arthrodesis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrodesis at L5-S1.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neuroplasty and/or transposition; median nerve at 
carpal tunnel. 
 
You asked the Plan to pre-approve a neuroplasty and/or transposition. You say that the enrollee no longer feels 
relief from injections. The Plan denied your request. The Plan says records do not show documentation of 
physical exam findings consistent with carpal tunnel syndrome or electrodiagnostic testing confirming the 
diagnosis of carpal tunnel syndrome. 
 
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 neuroplasty and/or transposition. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the results from the injection provided on July 18, 2023, are not clearly documented. There are no electrodiagnostic studies provided to corroborate pathology. No compelling rationale 
is presented, or extenuating circumstances noted to support the medical necessity of this request as an 
exception. 
 
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 neuroplasty and/or transposition have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a neuroplasty and/or transposition; median nerve at carpal tunnel.
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 options, patient weight capacity up to and including 300 pounds (K0861) and additional items and 
accessories (codes E1002, E2300, E1012, and E2311). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the DME is medically 
necessary. The Plan denied your request. The Plan says  the requirements for coverage are not 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 the durable medical equipment (DME). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee does not have a qualifying diagnosis of a neurological 
condition, myopathy, or congenital skeletal deformity for a group 3 power wheelchair. 
 
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 durable medical equipment (DME) 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 
options, patient weight capacity up to and including 300 pounds (K0861) and additional items and accessories 
(codes E1002, E2300, E1012, and E2311).
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. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair. You say that the enrollee has progressed 
beyond the useful capacity of a group two power mobility device. You also say that the enrollee cannot 
perform an independent weight shift to a position themselves for clothing management. The Plan denied your 
request. The Plan says the enrollee does not have medical need for multiple power options included with the 
requested Group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when 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 a Group 3 power wheelchair. Our 
reviewer says that the requested Group 3 power wheelchair with multiple power options is not medically 
necessary. Our physician reviewer found the provided documentation indicates that the enrollee has a 
neurologic disorder with functional deficits. The documentation does not indicate that the enrollee has any 
pressure injuries or requires intermittent catheterization of the bladder or have spasticity that would necessitate 
power tilt or recline. Although the enrollees condition may meet criteria for a power wheelchair the criteria for 
this specifically requested power wheelchair with multiple power options including power tilt and recline are 
not 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 a Group 3 power wheelchair 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (V5261) provided on March 16, 2023. 
 
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 V5261 is "Hearing aid, digital, binaural, bte". 
 
We asked our coder 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 services. Our reviewer says that the use of code V5261 is 
not supported by the records provided. Our reviewer found the code V5261 represents behind the ear (BTE). In 
this case, there is a more specific code that should be reported for service provided. 
 We looked at this coder's review, the file, and Medicare rules. 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 (V5261) provided on March 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  a power wheelchair (K0823). 
 
You asked the Plan to pre-approve the power wheelchair. You say that you cannot maneuver the power scooter 
that you currently have and would like to be approved for a new heavy duty power wheelchair. The Plan denied 
your request. The Plan says this request for a power wheelchair does not meet criteria.  
 
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 power wheelchair. Our physician reviewer found you are noted to have limited community mobility. You can perform your daily activities and 
ambulate in the home with the assistance of a quad cane, and you are noted to have a rollator. You have a 
history of knee and shoulder osteoarthritis with surgery with limited upper extremity strength and range of 
motion. You cannot propel a manual wheelchair. You may benefit from a power scooter for improving your 
mobility, but there is insufficient documentation indicating that you can safely use it and that your home is 
accessible for it. You noted to have had a previous power scooter that was returned because you could not 
operate it. Therefore, the power scooter 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 the power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve  a power wheelchair (K0823).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on May 9, 2023. 
 
You asked the Plan to pay for the lab panel. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. The lab panel in this case was billed with multiple codes and not one 
unit of one code as required by LCA A58720. Based on this information, we decided that Medicare rules for 
coverage of the lab panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
lab panel provided on May 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on February 10, 2023, and May 5, 
2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. The lab panel in this case was billed with multiple codes, and not one 
unit of one code as required by LCA A58710. Based on this information, we decided that Medicare rules for coverage of the panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
panel provided on February 10, 2023, and May 5, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that it is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
requires assistance with mobility and performing daily activities as well as taking the enrollee's medications. 
The enrollee has not had a recent hospitalization or acute change in the enrollee's medical conditions. The 
enrollee does not require complex wound care, tracheostomy management or IV medication. The enrollee 
requires assistance and supervision, but this does not require skilled nursing care. 
 
Therefore, the additional 7 visits of home health skilled nursing care are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OneOme RightMed genetics test (0350U) provided on 
April 6, 2023. 
 
You asked the Plan to pay for the OneOme RightMed genetics test. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this test has not been approved by the FDA. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS is covered when the test has an FDA 
approval or clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that this test does not have FDA approval or 
clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for 
coverage of the OneOme RightMed genetics test have not been met. Therefore, we decided that the Plan does 
not have to pay for the OneOme RightMed genetics test (0350U) provided on April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223) provided on November 23, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the records do not 
indicate the date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for CPT code 99223 is not supported in the medical record. Specifically, while the 
records do show an admission date of November 23, 2022, the records do not include the actual date for the 
services provided. As such, the billed services cannot be verified for the date of service in question. 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 (99223) provided on November 23, 2022.
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 would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee's condition does not meet Medicare 
guidelines for admission to an IRF.  
 
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, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy 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 group 2 standard power wheelchair, captains chair, 
patient weight capacity up to and including 300 pounds (K0823). 
 
You asked the Plan to pre-approve the power wheelchair. You say that you cannot walk in bad weather, and 
during good weather you would like to go out and enjoy the day.  The Plan denied your request. The Plan says  
you do not meet medical necessity for the requested 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 power wheelchair. Our physician 
reviewer found the documentation available for review does not support that you require a power mobility 
device to accomplish mobility related self-care tasks in the home. There is no indication you are unable to use 
an alternative assistive 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 the power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a group 2 standard power wheelchair, captains chair, patient weight capacity up to 
and including 300 pounds (K0823).
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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for sepsis, respiratory failure and abdominal pain. Medical problems are stable. There are no 
complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 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 this 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 19, 2022, to 
October 14, 2022. 
 You asked the Plan to pay for the home health services. You say that you have submitted the required NOA. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 22, 2022. The NOA was not received by the Plan until February 6, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from September 19, 2022, to October 14, 2022.