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

 
We decided that the Plan has to pre-approve the electrical connection (E2311), expandable controller (E2377), 
and harness (E2313).  
 
You asked the Plan to pre-approve The electrical connection, expandable controller, and harness. You say that 
the items are medically necessary. The Plan denied your request. The Plan says that the items are not medically 
necessary. 
 
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 the electrical connection, expandable 
controller, and harness. Our reviewer says that the requested items are considered medically reasonable and 
necessary in this case. Our physician reviewer found the complexity of the enrollee's 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. 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 the electrical connection, expandable controller, and harness have been met. 
Therefore, we decided that the Plan has to pre-approve the electrical connection (E2311), expandable controller 
(E2377), and harness (E2313).   
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick catheter system. 
 
You asked the Plan to pre-approve a Purewick catheter system. You say that you are requesting reconsideration 
of the denied authorization. The Plan denied your request. The Plan says there is no clinical documentation 
showing why the enrollee is not able to use a standard female external collection device. 
 
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 Purewick catheter system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee is noted to suffer from neurogenic bladder and 
incontinence, for which a Foley catheter was previously placed. There is no evidence that the Foley catheter 
was ineffective. There is no evidence that an external catheter was tried, cannot be used or was ineffective. 
 
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 Purewick catheter system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Purewick catheter system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96366 for date of service March 9, 2023. 
 
You asked the Plan to pay for procedure code 96366. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 96366 is intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary 
procedure). 
 
 
 We find that CPT code 96366 is not supported in the medical record. Specifically, the documentation submitted 
did not include detail to support intravenous infusion. In addition, the time spent of 91 or more minutes was not 
provided in the medical records. Based on this information, we decided that Medicare rules for coverage of 
procedure code 96366 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 96366 for date of service March 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair accessory, Kit Assay Transit Securement 
Package Occupied TB3 Seat (K0108). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the transit kit does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve wheelchair accessory, Kit Assay Transit Securement 
Package Occupied TB3 Seat (K0108).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for  practitioner services provided on February 15, 2023, billed with code 
G2067. 
 
You asked the Plan to pay for  the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that the provider is not certified and cannot be 
paid. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the specific denial rationale provided by the Plan is not supported. 
The Plan states that the servicing provider is not certified, however we have verified that the provider is 
Medicare certified. As such, denial of payment is not substantiated. Therefore, we decided that the Plan has to 
pay for  practitioner services provided on February 15, 2023, billed with code G2067.  
 
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 pay for the home health services rendered from June 20, 2022, to 
July 17, 2022. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. 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 June 20, 2022. The NOA was not received by the Plan until August 11, 
2022. 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 the home health services 
rendered from June 20, 2022, to July 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the vitamin injections and a therapeutic prophylactic injection.

You asked the Plan to pay for the injections. The Plan denied your request. The Plan says the vitamin injections and the therapeutic prophylactic injection are not medically necessary.

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 the injections. Our reviewer says that the vitamin injections are not medically necessary. Our physician reviewer found that there was insufficient support made for these injections as there was no objective evidence from the testing the enrollee had a vitamin deficiency or that they could not reasonably get enough vitamin dosing from a healthy diet or oral supplementation to meet needs. Therefore, the request for the vitamin injections and therapeutic prophylactic injection is not considered 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 injections have not been met. Therefore, we decided that the Plan does not have to pay for the vitamin injections and the therapeutic prophylactic injection provided on February 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostatic artery embolization (36247). 
 
You asked the Plan to pre-approve prostatic artery embolization. You say that this is medically necessary. The 
Plan denied your request. The Plan says the requested service is experimental and investigational. 
 
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 prostatic artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found prostatic arterial embolization (PAE) is considered an experimental 
technique to treat symptomatic benign prostatic hyperplasia (BPH). Very limited studies have demonstrated 
possible short-term safety and efficacy. The most recent guidelines do not recommend this procedure outside of 
a clinical trial setting due to the heterogeneity in the available literature and safety concerns regarding radiation 
exposure, postembolization syndrome, vascular access, technical feasibility, higher clinical failure rate 
compared with more traditional methods. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostatic artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve prostatic artery embolization (36247).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft (D7953) for tooth #30 provided
on December 2, 2022.

You asked the Plan to pay for the dental service. You say that the bone graft was absolute medical necessity
and you would like the claim to be sent for payment. The Plan denied your request. The Plan says the denial of
payment for this service is correct, because the bone replacement graft is not covered by the Plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone
replacement graft (D7953) for tooth #30 provided on December 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MNT services (97802, 97803) 
 
You asked the Plan to pre-approve MNT services. You say that the requested MNT services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are not a covered 
benefit as prescribed in this case. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pre-approve MNT services (97802, 97803)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with single power 
option (K0856) and additional items and accessories (codes E0955, E0956, E1002, E1028, E2300, E2310, 
E2361, E2607, E2620, and K0040). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair with single power option and 
additional items and accessories. You say that the requested wheelchair and accessories are medically 
necessary to meet the enrollee's current needs. The Plan denied your request. The Plan says the enrollee does 
not have medical need for a single power option (power tilt) included with K0856 group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with power seating 
system, tilt only, may be covered if 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 standard power wheelchair 
with single power option and additional items and accessories. Our reviewer says that the enrollee does not 
meet the coverage criteria for a group 3 standard power wheelchair with single power option. Our physician 
reviewer found 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. Our reviewer also found that 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 standard power wheelchair with single power option 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 single power option (K0856) and additional items and accessories 
(codes E0955, E0956, E1002, E1028, E2300, E2310, E2361, E2607, E2620, and K0040).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tempus xG testing (81479) provided on January 7, 2023. 
 
You asked the Plan to pay for Tempus xG testing. You say that this test was reasonable and necessary. The 
Plan denied your request. The Plan says this test 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 pay for Tempus xG testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records provided in this case do not document that the enrollee has either recurrent, 
relapsed, refractory, metastatic, or advanced stage III or IV cancer and has not been previously tested with the 
same test using NGS for the same cancer genetic content and has decided to seek further cancer treatment (e.g., 
therapeutic chemotherapy) as required by the NCD for coverage.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tempus xG testing have not been met. Therefore, we decided that the Plan does 
not have to pay for Tempus xG testing (81479) provided on January 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150 and 87641 for date of service 
September 21, 2022. 
 
You asked the Plan to pay for procedure codes 87150 and 87641. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that XU modifier is used to reflect unusual non-
overlapping Service, the use of a service that is distinct because it does not overlap usual components of the 
main service. 
 
We looked at the file and Medicare rules. The documentation shows that codes 87150 and 87641 were billed 
with modifier XU. The documentation does not support that these services were distinct or independent from 
the other services performed. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 87150 and 87641 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 87150 and 87641 for date of service September 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says admission to an LTACH does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you were admitted with aortic dissection and required operative intervention. The 
record indicates that you have had a complicated hospital course and still have ongoing acute medical issues 
that, although improving, require acute care services before you are able to transition to a lower level of 
care. You continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH 
facility. The elements of the coverage rules are not satisfied.  The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat belt and calf pads for a power wheelchair.

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 covered.

The Plan must follow Medicare rules. The rules say that a Column II code is included in the allowance for the corresponding Column I code when provided at the same time. When multiple codes are listed in column I, all the codes in column II relate to each code in column I.

We looked at the file and Medicare rules. The requested seat belt (E0978) and calf pads (E0995) are included in the approved power wheelchair (K0856). These services cannot be separately approved. Therefore, we decided that the Plan does not have to pre-approve a seat belt and calf pads for a power wheelchair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve physical therapy services with an out-of-network provider. You say that the 
services are necessary. The Plan denied your request. The Plan says the requested services are available in-
network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
   
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you are requesting reconsideration due to 
medical necessity. The Plan denied your request. The Plan says the request for a ventilator is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe obesity with a 
body mass index (BMI) greater than 90, obstructive sleep apnea on continuous positive airway pressure 
(CPAP), and obesity hypoventilation syndrome.  There is no diagnosis of COPD, thoracic restrictive disease, or 
neuromuscular disease. The enrollee was recently hospitalized with arterial blood gas (ABG) showing acute on 
chronic hypercarbic respiratory failure. The enrollee improved on bilevel positive airway pressure 
(BiPAP). Medicare does not cover a home ventilator for the treatment of obesity hypoventilation syndrome, or 
when used at settings that can be provided with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).