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

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with a single power option 
(recline) and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with a single power option. You say that this is 
medically necessary due to your nerve damage. You say that you cannot physically use your arms to wheel 
yourself. You also say that your leg strength is declining. The Plan denied your request. The Plan says the 
records do not show a medical need for the requested power option. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with a single power 
option may be covered when the coverage 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 with a 
single power option. Our reviewer says that the requested Group 3 power wheelchair with single power option 
is not medically necessary. Our physician reviewer found the provided documentation does not show that you 
have any pressure injuries or require intermittent catheterization of the bladder or have spasticity. Therefore, 
the reviewer found that the requested Group 3 power wheelchair with single power option 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 Group 3 power wheelchair with a single power option have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with a single 
power option (recline) and accessories.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like to request reconsideration of the 
denied SNF services and that the services requested are medically necessary. The Plan denied your request. 
The Plan says that the skilled nursing facility (SNF) services requested do not meet the requirements for 
approval. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee would benefit from daily skilled nursing facility care for more intensive 
therapy to continue to improve their level of mobility and function. Continuing to maintain and improve their 
mobility and function is imperative if they are to undergo orthopedic surgery to release their hip and knee 
contracture. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental abutments. 
 
You asked the Plan to pre-approve dental abutments. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 dental abutments have been met. Specifically, medical records were not submitted to determine if the abutments are necessary. Therefore, we 
decided that the Plan does not have to pre-approve dental abutments.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PRP injections. 
 
You asked the Plan to pre-approve PRP injections. You say that this procedure is a cost-effective alternative to 
knee replacement and is less invasive for the enrollee. The Plan denied your request. The Plan says this is 
investigational and unproven treatment is not covered. 
 
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 PRP injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is an experimental/ investigational procedure and it is the subject of ongoing clinical trials. 
Therefore, the request is deemed 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 PRP injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve platelet-rich plasma (PRP) injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upgraded electronics (E2311, E2313, E2377), power 
standing system (E2301), and push handles (K0108 x 2). 
 
You asked the Plan to pre-approve the power wheelchair components. You say that you are appealing 
procedure codes E2311 and E2301. You say that Medicare has reviewed, approved, and deemed them 
medically necessary. The Plan denied your request. The Plan says the notes do not show a medical need to 
control the power options through the joystick. The Plan also says that push handles and a power standing 
system do not serve a medical purpose and cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
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 upgraded electronics. Our reviewer 
says that the requested upgraded electronics are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation indicates that the enrollee has adequate strength to 
manage standard power drives. Therefore, the reviewer found that the requested upgraded electronics are 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 the upgraded electronics have not been met. Additionally, the power standing 
system and push handles do not serve a purpose that is primarily medical in nature. Therefore, we decided that 
the Plan does not have to pre-approve upgraded electronics (E2311, E2313, E2377), power standing system 
(E2301), and push handles (K0108 x 2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vagus nerve stimulation (VNS). 
 
You asked the Plan to pre-approve a VNS. You say that this procedure would benefit the enrollee. The Plan 
denied your request. The Plan says there are other treatment options available. 
 
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 VNS. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has spasticity in the setting of hemiparesis and hemiplegia secondary to stroke.  
There is insufficient literature to support the safety and efficacy, as defined by Medicare rules, of the requested 
service. 
 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 VNS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a vagus nerve stimulation (VNS).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
September 18, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $40 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for a specialist office visit provided on September 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. 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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental in spine surgery.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency care (99285) provided on May 10, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that 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 99285 is "Emergency department visit for the evaluation and management of a patient, which requires a 
medically appropriate history and/or examination and high level of medical decision making". 
 
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 99285 is 
supported by the records provided. Our reviewer found that that the documentation supports a medically 
appropriate history and exam as well as a high level of medical decision-making. Although the case is an 
example of an acute injury without signs of life or body threat, the enrollee did require parenteral controlled 
substances for pain control. The use of intramuscular (IM) Dilaudid, increased risk level making this a level 5 
visit. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the emergency care (99285) provided on May 10, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the SNF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet the criteria for the SNF admission. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2751) and a core build-up (D2950) for tooth 
#12. 
 
You asked the Plan to pre-approve the dental services. You say that this dental work is medically necessary. 
The Plan denied your request. The Plan says the requested dental work is not medically necessary. 
 
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 the dental 
services 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 the dental services. Our reviewer says 
that this dental work is not medically necessary. Our physician reviewer found a review of the documentation 
provided did not indicate that tooth #12 exhibited significant coronal breakdown due to caries or fracture to 
warrant these services. 
 
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 the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2751) and a core build-up (D2950) for tooth #12.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on August 
09, 2023. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for outpatient surgery/Medicare-coveredsurgery. 
 
You have been asked to pay a $200 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/Medicare-coveredsurgery benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for an outpatient surgery provided on August 09, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued therapy with Retacrit (Q5106). 
 
You asked the Plan to pre-approve Retacrit. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says there is no documented dose adjustment of therapy with corresponding 
documented hemoglobin (Hgb) levels to indicate maintenance therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Retacrit. Our reviewer says that the 
request for continued Retacrit therapy is not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has a diagnosis of anemia in chronic kidney disease, stage IV and not on dialysis. 
The record indicates that the enrollee has a hematocrit of over 40 and has not undergone dose adjustment. The 
Food and Drug Administration (FDA) has stated that the requested drug is indicated for the enrollee's condition. Therefore, the reviewer found that the request for continued Retacrit therapy 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 Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued therapy with Retacrit (Q5106).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 21, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service September 19, 
2023. 
 
You asked the Plan to pay for the billed testing. The Plan denied your request. The Plan says one code must be 
submitted for the panel. 
 
 The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
The file shows that a urinary tract infection panel was billed using codes 87500, 87641, 87798, 87491, 87496, 
87511, 87529, 87532, 87563, 87591, 87661, 87481, 87651, 87653, and G0452. We looked at the file and 
Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no 
evidence that multiple procedures, multiple methodologies, or multiple kits were used in this case. As such, a 
single code with one unit of service should be used. Based on this information, we decided that Medicare rules 
for coverage of the testing panel have not been met. Therefore, we decided that the Plan does not have to pay 
for the panel testing billed for date of service September 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for hip surgery provided on July 26, 2023, to 
July 28, 2023. 
 
You asked the Plan to waive the coinsurance for hip surgery. You say that you were under the impression 
because you saw this provided previously, that the amount would be the same. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for outpatient surgery. 
 
You have been asked to pay 20% coinsurance for hip surgery. This item/service falls within the outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. You have been asked to pay a total of $2551.08 for outpatient surgery. Therefore, we decided that the 
Plan does not have to waive the coinsurance for hip surgery provided on July 26, 2023, to July 28, 2023.