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

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and 
accessories (E0955, E1007, E1012, E1028, E2300, E2311, E2313, E2361, E2377, E2607, E2620, K0040). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the clinical 
documentation provided shows justification for the reason of denial. The Plan denied your request. The Plan 
says the enrollee does not have medical need for multiple power options included with a group 3 power 
wheelchair. The Plan also says the electronic connection, expandable controller harness, and expandable 
controller cannot be covered as it is not medically necessary to control the three requested power options 
through the joystick (drive interface). 
 
The Plan 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 power wheelchair and accessories. 
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 Parkinson's disease and poor mobility. The record does 
not support the assertion of high risk for skin injury as no evidence of poor nutrition, risk of shear, or 
incontinence. Per L33789, the enrollee does not have high risk for skin breakdown, use a catheter 
intermittently, have spasticity or require an alternative means of managing power drive. Therefore, the enrollee 
does not meet criteria for approval of the requested wheelchair and accessories. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple power option, 
sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and accessories (E0955, 
E1007, E1012, E1028, E2300, E2311, E2313, E2361, E2377, E2607, E2620, K0040).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee's recent hospitalization was 
treated accordingly with bilevel positive airway pressure (BIPAP) therapy with appropriate response. The 
enrollee documentation does not support BIPAP failure or escalation of therapy.  Hence, per documentation 
and data provided, no indication for home ventilator. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for two office visits and foot orthotics provided from 
March 13, 2023, to August 21, 2023. 
 
You asked the Plan to waive the cost for office visits and orthotics. You say that you feel you are being 
overcharged for the durable medical equipment. 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 $20 
copayment for physician/practitioner services, including doctors office visits, and a 20% coinsurance for 
durable medical equipment (DME) and related supplies.  
 You have been asked to pay a $172.92 total cost for office visits and orthotics. This item/service falls within 
the physician/practitioner services, including doctors office visits, and durable medical equipment (DME) and 
related supplies 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 cost for two office visits and foot orthotics 
provided from March 13, 2023, to August 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frames, the progressive lens, the anti-reflective 
coating, the lens, and the tint provided on December 19, 2022. 
 
You asked the Plan to pay for the deluxe frames, the progressive lens, the anti-reflective coating, the lens, and 
the tint . You say that you should be reimbursed the $200 for the eyewear. You say the provider and the plan 
indicated that the provider was in-network. The Plan denied your request. The Plan says the services are not 
covered benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when received by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the deluxe frames, the progressive lens, the anti-
reflective coating, the lens, and the tint have not been met. Therefore, we decided that the Plan does not have to 
pay for the deluxe frames, the progressive lens, the anti-reflective coating, the lens, and the tint provided on 
December 19, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the interpretation of the left knee x-ray provided on May 25, 2023. 
 
You asked the Plan to pay for the x-ray interpretation. You say that this was medically necessary, and valid 
diagnosis codes were reported. The Plan denied your request. The Plan says that this code 73560 was billed 
with modifier -LT with no corresponding left-sided diagnosis code. 
 
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 We find that the Plan's denial rationale is not supported. The Plan 
indicates that since modifier -LT was used for one of the x-rays, a left-sided diagnosis code must also be 
reported. This is not supported by review of the records. The primary diagnosis code reported was Z47.1, 
defined as "aftercare following joint replacement surgery". The knee prosthesis only exists on the right side. 
Both knees were imaged as part of the aftercare for this surgery. We find that there is no need for an additional 
left-sided diagnosis code just because the left knee was also imaged. As such, we find that the denial of 
payment is not substantiated. Therefore, we decided that the Plan has to pay for the interpretation of the left 
knee x-ray provided on May 25, 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services rendered from April 17, 2023, to 
April 20, 2023. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says reasonable clinical evidence within the health 
record must be present to clinically validate these diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871. 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 the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee presented with shortness of breath, congestion, sputum production and lower extremity 
swelling.  There appears to be evidence of chronic obstructive pulmonary disease, congestive heart failure and 
mucous plugging.  There is no evidence of sepsis (i.e., hypotension, hypoperfusion, organ failure).  As such, 
the billing of A41.9 and R65.20 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services rendered from April 17, 2023, to April 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the L2 kyphoplasty. 
 
You asked the Plan to pre-approve the L2 kyphoplasty. You say that the most recent imaging should be 
reviewed, and the original decision should be reversed. The Plan denied your request. The Plan says the L2 
kyphoplasty is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the L2 kyphoplasty. Our reviewer says 
that the L2 kyphoplasty is not medically necessary. Our physician reviewer found that the LCD coverage 
criteria for the requested L2 kyphoplasty has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the L2 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the L2 kyphoplasty.
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 (tilt/recline) and accessories. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the notes do not show that a medical need for these power options. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee has 
intact skin, with no risk for skin breakdown. The enrollee does not use a catheter intermittently, have spasticity, 
or require an alternate means of managing the power drive. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services 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 (tilt/recline) and accessories.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 for date of service April 18, 2023. 
 
You asked the Plan to pay for procedure code 99285. 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 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 procedure code 99285. Our reviewer says that the 
documentation does not support the code billed. Our reviewer found the documentation do not support this high 
level of billing based on the medical decision-making complexity. Therefore, code 99285 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 for date of service April 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (E0952, 
E0953, E0955, E1007, E1012, E1028, E2300, E2311, E2313, E2363, E2377, E2605, E2620, K0108, K0861). 
 
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices are covered when specific 
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 and 
accessories. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
enrollee does not have high risk for skin breakdown, use a catheter intermittently, have spasticity or require an 
alternative means of managing power drive. He has 3-4/5 strength in upper extremities. The power seat 
elevation is requested to assist transfers, but it is not clear he requires seat elevation for transfers in the home.  
 
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 and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (E0952, E0953, 
E0955, E1007, E1012, E1028, E2300, E2311, E2313, E2363, E2377, E2605, E2620, K0108, K0861).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary Our physician reviewer found based upon review of 
the records provided this enrollee does not meet the criteria for December 2, 2023 forward as this enrollee was 
not shown to be a danger to herself or others. There were no delusions, auditory or visual hallucinations noted. 
She was cooperative/compliant with treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis, single upright, thigh and calf, with adjustable 
flexion and extension joint (L1843) and an addition to lower extremity orthosis, suspension sleeve (L2397) 
provided on July 19, 2023. 
 
You asked the Plan to pay for a knee orthosis and suspension sleeve. You say that you have forwarded medical 
records and state the services are medically necessary for the enrollee. The Plan denied your request. The Plan 
says the request is not medically necessary because the records show the enrollee does not have a recent knee 
injury, or knee surgeries, documented in the records received. 
 
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 a knee orthosis and suspension sleeve. 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 unilateral primary osteoarthritis of the right knee. The 
record sent by the provider indicates the enrollee had a visit with their doctor on May 23, 2023, addressing 
diabetes, skin discoloration on legs, chronic ankle pain, and upper respiratory symptoms. L33318 criteria have 
not been met for the knee orthosis and suspension sleeve. The documentation does not reveal evidence of 
instability, recent injury, or trauma to the knees. 
 
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 knee orthosis and suspension sleeve have not been met. Therefore, we decided 
that the Plan does not have to pay for a knee orthosis, single upright, thigh and calf, with adjustable flexion and 
extension joint (L1843) and an addition to lower extremity orthosis, suspension sleeve (L2397) provided on 
July 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a scooter. You say that you need the motorized chair for mobility. The Plan 
denied your request. The Plan says the requested scooter is not medically necessary under Medicare. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a scooter. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found you have a painful right foot with an ulcer. 
The device is requested to assist in community mobility. Per NCD 280.3, the device is not necessary for home 
self-care activities. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power operated vehicle (K0800).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 8, 2023, billed with 
codes 81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81209, 81314, 81334, 81345, 
81272, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. 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 if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the 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 an NGS 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 genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
July 8, 2023, billed with codes 81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 
81209, 81314, 81334, 81345, 81272, and 81479.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot inserts (L3000x2). 
 
You asked the Plan to pre-approve foot orthotics. You say that you have been dealing with your foot issue for 
several decades and strongly feel it is medically necessary to have a new shoe insert. Your current insert is now 
10 years old, worn out and no longer providing the support needed. The Plan denied your request. The Plan 
says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot inserts (L3000x2).