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

 
We decided that the Plan has to pre-approve a replacement prosthesis (L5781, L5968, L5981). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no description of the current foot condition. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. 
 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that the records satisfy the Medicare requirements in documentation the enrollee's K3 function, as well as 
the need for a new prosthesis. Flex-walk style feet (and their normal addition codes) are part of the basic 
standard of care for all community K3 amputee ambulators given that the evidence of their benefits and 
superiority to less sophisticated alternatives are so well proven and long standing. The scientific literature in 
this space is abundant and consistently supportive of the benefits of using vacuum suspension in properly 
selected amputee patients. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve a replacement prosthesis (L5781, L5968, L5981).  
 
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: 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 you would like to request 
reconsideration of the denied home health services and that the services requested are 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, but they live in an assisted living facility. 
Therefore, the continued home health skilled nursing care and home health aide assistance 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace (L0457) provided on June 26, 2023. 
 
You asked the Plan to pay for the back brace. You say that the item 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 mention of the need for back bracing or specific physical examination of the back 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 the back brace 
(L0457) provided on June 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve in-network tertiary level Otolaryngology visits. 
 
You asked the Plan to pre-approve in-network tertiary level Otolaryngology visits. You say that the requested 
in-network tertiary Otolaryngology visit is medically necessary. The Plan denied your request. The Plan says 
the requested in-network tertiary Otolaryngology visit is not medically necessary. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 in-network tertiary level 
Otolaryngology visits. Our reviewer says that the requested in-network tertiary Otolaryngology visit is not 
medically necessary. Our physician reviewer found the record indicates that the enrollee has impacted 
cerumen. The record documents that the plan has indicated that in network non-tertiary care providers are 
available and adequate to meet the enrollee's medical needs. The elements of the coverage criteria are not 
satisfied. The requested service is not 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 in-network tertiary level Otolaryngology visits have not been met. Therefore, 
we decided that the Plan does not have to pre-approve in-network tertiary level Otolaryngology visits.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
when three or more power seating functions/actuators/motors are provided, one unit of E2311, one unit of 
E2313, and one unit of E2377 are allowed. The Plan denied your request. The Plan says that although there are 
three requested power options (tilt, recline and elevating leg rests), there is not a medical need to control these 
power options through the joystick. 
 
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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are considered medically reasonable 
and necessary in this case. Our physician reviewer found the patient is functionally non-ambulatory and 
requires a power wheelchair for mobility and performing daily activities. They cannot perform pressure relief 
independently due to upper extremity weakness and require a power wheelchair with power tilt and recline for 
adequate pressure relief and positioning. Power elevating leg rests are required for positioning of the lower 
extremities and lower extremity spasticity. Our reviewer found that the complexity of the patients seating and 
positioning needs necessitates a more complex group 3 power wheelchair base. The expandable controller with 
harness and electronic connection are necessary to operate the group 3 power wheelchair base and the three 
power options via a joystick. Our physician reviewer also found that these components are required to operate 
3 or more power options on 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 an electronic connection, harness, and expandable controller have been met. 
Therefore, we decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on May 5, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation 
submitted did not include documentation to determine a relationship between the ordering provider and the 
enrollee at the time of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services have been met. The 
submitted documentation does not contain medical records from the non-contract provider. Therefore, we 
decided that the Plan does not have to pay for the drug testing services provided on May 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown - porcelain/ceramic (D6740) on teeth 
numbers 4 and 6 and pontic - porcelain/ceramic (D6245) on teeth numbers 5 and 7. 
 
  You asked the Plan to pre-approve retainer crown - porcelain/ceramic (D6740) on teeth numbers 4 and 6 and 
pontic - porcelain/ceramic (D6245) on teeth numbers 5 and 7. You say that the enrollee does not want to go 
from a fixed bridge to a removable appliance. The Plan denied your request. The Plan says the information by 
the dentist does not state why a denture cannot be used to replace the missing teeth. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers retainer 
crown - porcelain/ceramic (D6740) on teeth numbers 4 and 6 and pontic - porcelain/ceramic (D6245) on teeth 
numbers 5 and 7 when the services are medically necessary and reasonable.  
 
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 retainer crown - porcelain/ceramic 
(D6740) on teeth numbers 4 and 6 and pontic - porcelain/ceramic (D6245) on teeth numbers 5 and 7. Our 
reviewer says that based on the information provided, the requested services are not medically necessary. Our 
physician reviewer found an alternative treatment of a removable partial denture is available to the enrollee. 
Our physician reviewer also found that there were no clinical notes included in the appeal to review, as well as 
there was no documentation included of why this alternative could not treat and benefit the enrollee, as it is an 
option to replace the teeth that will be removed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of retainer crown - porcelain/ceramic (D6740) on teeth numbers 4 and 6 and 
pontic - porcelain/ceramic (D6245) on teeth numbers 5 and 7 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve retainer crown - porcelain/ceramic (D6740) on teeth numbers 4 and 6 and 
pontic - porcelain/ceramic (D6245) on teeth numbers 5 and 7.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 22, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that these services were provided to the enrollee. The 
Plan denied your request. The Plan says these services were billed incorrectly. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Genicular Artery Embolization. 
 
You asked the Plan to pre-approve a Genicular Artery Embolization. You say that this service is medically 
necessary. The Plan denied your request. The Plan says this service 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 a Genicular Artery Embolization. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this service 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 a Genicular Artery Embolization have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Genicular Artery Embolization.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for massage therapy received from May 4, 2023, to July 13, 
2023. 
 
You asked the Plan to pay for massage therapy. You say that massage therapy is necessary to assist with 
several health concerns. The Plan denied your request. The Plan says you have met your annual limit for 
massage therapy coverage. 
 
  The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. The Plan 
includes a supplemental benefit for massage therapy which covers up to 12 massage therapy visits per year. 
You received 12 covered visits from January 5, 2023, to April 27, 2023; therefore, this benefit was exhausted. 
Therefore, we decided that the Plan does not have to pay for massage therapy received from May 4, 2023, to 
July 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on March 14, 2023, billed with 
codes 87640, 87481, 87900, 87652, 87500, 87798 and 87799. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on March 14, 2023, billed with codes 87640, 87481, 87900, 87652, 87500, 87798 and 87799.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on May 31, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 5, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the services provided on 
May 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service May 3, 2023.  
 You asked the Plan to pay for procedure code 99233. You say that the claim is billed correctly and should be 
paid. 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 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.  
 
In this case, the MUE for CPT code 99233 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. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99233 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99233 billed for date of service May 3, 2023.
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 a lower level of care is not safe or sufficient and will 
not give the enrollee the opportunity to gain a higher level of functioning. The Plan denied your request. The 
Plan says the request is not medically necessary.  
 
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 that 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. 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.  
 
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 review has determined that 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 does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, in an intensive rehabilitation therapy program. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a robotic right genitofemoral neurectomy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not document a trial and 
failure of non-invasive measures, including medication management for the enrollee's chronic neuropathic 
pain, as is the standard of care for this condition. The requested procedure is therefore not reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a robotic right genitofemoral neurectomy.