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

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and one power seating system motor (E2310). 
 
You asked the Plan to pre-approve an electronic connection. You say that the patient needs this wheelchair to 
live an independent lifestyle. The Plan denied your request. The Plan says because the enrollee is able to the 
control the power option with its own switch, there is no need to control the power option through the joystick. 
 
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 an electronic connection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient has obesity and diabetes and impaired ambulation. The patient is able to 
toilet independently using a wheelchair. Our reviewer also found that the patient has adequate strength to 
manage standard power drives. 
 
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 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and one power seating 
system motor (E2310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) and periapical each 
additional radiographic image (D0230) provided on August 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the periapical each additional radiographic image has already been 
exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the periapical each additional radiographic image was exhausted on date of service August 1, 2023. A limited oral evaluation is not a covered service. Therefore, we decided that the Plan does not 
have to pay for limited oral evaluation (D0140) and periapical each additional radiographic image (D0230) 
provided on August 1, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says you do not meet the criteria for SNF services. 
 
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 require the level of observation and treatment provided in terms of 
physician oversight and skilled nursing care. You were re-admitted to the hospital from a skilled nursing 
facility for an exacerbation of your atrial fibrillation/flutter, and this is not a new diagnosis. You do not require 
daily skilled nursing services, including complex wound management, tracheostomy care, bowel and bladder 
training and tube feeding, or administration of intravenous medications. You have not had a significant decline 
in your level of function and mobility since being re-admitted to the hospital. Currently you are requiring 
supervision to contact guard assistance for mobility and daily activities, and this does not require the intensity 
of therapy services provided in the skilled nursing facility 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 SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration based on medical 
necessity. The Plan denied your request. The Plan says criteria for admission to the acute inpatient 
rehabilitation setting have not been met.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says daily imaging is neither necessary nor useful in this case. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the treatment itself is not disputed in this case but rather the need for image guidance. At issue is the 
need for daily image guidance; it appears that the request is for IGRT. Usually IGRT is used when critical 
structures are abutting or in close proximity to the target that is being treated to high doses. This situation does 
not apply to this patient for which the target lesion can be seen on the skin to assist in daily set up. When treating skin cancers, there is generally not a need for IGRT unless deep structures are being treated. Certainly 
using ultrasound on a daily basis is not unreasonable to offer but not necessary. The device itself is FDA 
approved for use with ultrasound though that in and of itself does not mean that daily imaging is necessary but 
simply that the device was designed to incorporate this functionality. Therefore to bill for daily simple 
simulations (77280) and/or IGRT for a technology for which need has not been established by published data 
or supported by consensus guidelines is not necessary. This would not be furnished in accordance with 
accepted standards of medical practice. 
 
 
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 ultrasound-guided radiation therapy (IGRT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Battery Genomics TruSight Myeloid Panel testing 
(81455). 
 
 You asked the Plan to pre-approve genetic testing. You say that the genomics trusight myeloid panel has 
allowed considerable advances in the genetics of these syndromes with 51 genes having been identified to date. 
The test is necessary. The Plan denied your request. The Plan says a technical assessment (TA) has not been 
satisfactorily completed by MolDX for the requested test. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. MolDX has instituted a process for completing a Technical Assessment (TA) 
that ensures that tests are appropriate for their indications and are properly validated. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required technical 
assessment was approved and/or completed. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-
approve Battery Genomics TruSight Myeloid Panel testing (81455).
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 the enrollee's family says he has wounds, 
and he needs special equipment and pain management and that he needs aggressive home care. The Plan denied 
your request. The Plan says admission to a LTACH is not medically reasonable or necessary. 
 
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 the enrollee is receiving IV antibiotics, daily dressing changes, and he uses CPAP at 
night. The enrollee needs do not meet LTACH admission criteria. 
 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (code 90792) provided on 
May 5, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for code 90792. You say that the doctor rendered these services while the patient 
was in a nursing facility.  You said that the doctor could not contact insurance prior to rendering services. The 
Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. The provider has 
the responsibility of confirming insurance coverage and authorization prior to rendering services. Therefore, we 
decided that the Plan does not have to pay for outpatient mental health services (code 90792) provided on May 
5, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the Refresh Relivia solution purchased on September 8, 
2023. 
 
You asked the Plan to pay more for the Refresh Relivia solution. You say that the documents you sent are the 
originals and you signed the documents with the help of someone in the regional office. The Plan denied your 
request. The Plan says you had exhausted the OTC benefit in this period. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the Refresh 
Relivia solution is an OTC item. However, the Plan offers a $100 allowance every 3 months to be used toward 
the purchase of OTC items. Though the Plan offers this allowance for OTC items, the record shows that the 
remaining amount of 36 cents for this quarter was applied toward this purchase, and your OTC allowance has 
been exhausted. Therefore, we decided that the Plan does not have to pay more for the Refresh Relivia solution 
purchased on September 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E2361, E1028, E1007, E2300, E2613, 
E0955, E1028, E2209, E2377, E2313, E2311, E2607, K0040, E1010, and E0951). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and additional items and accessories. 
You say that the Medicare criteria for the Group 3 power wheelchair is met. You also say that the power 
seating options are justified in the therapy evaluation. The Plan denied your request. The Plan says the enrollee 
does not have medical need for the multiple power options included with the requested Group 3 power 
wheelchair with multiple power options. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
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 
and additional items and accessories. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found the enrollee has an above knee amputation. The enrollee requires occasional 
assistance to transfer and has 24-hour caregiver support. Our reviewer found that the enrollee has intact skin. 
Our physician reviewer also found that 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. 
 
 
 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 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 multiple power options (K0861) and additional items and accessories (codes E2361, E1028, 
E1007, E2300, E2613, E0955, E1028, E2209, E2377, E2313, E2311, E2607, K0040, E1010, and E0951).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have no lower body strength to go home on your 
own. You say you need acute care to assist you in your recovery. The Plan denied your request. The Plan says 
you do not meet Medicare guidelines for services in an inpatient rehabilitation facility.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 test provided on August 3, 2023. 
 
You asked the Plan to pay for the Guardant360 test. You say that this was a covered and medically necessary 
test. The Plan denied your request. The Plan says the claim for this molecular pathology testing included the 
required unique identifier, but you billed with the wrong procedure code. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim shows that the required unique identifier was 
reported. However, the MolDx registry says that the procedure code that should be billed for the Guardant360 
test is 0326U.  Instead, you billed this test with code 81479, which is an unlisted procedure code.  You must 
bill with the code approved by the MolDx registry for the Z-Code assigned to this test. Based on this 
information, we decided that Medicare rules for coverage of the Guardant360 test have not been met. 
Therefore, we decided that the Plan does not have to pay for the Guardant360 test provided on August 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fusion of spine in lower back (22612) using the 
StabiLink MIS Spinal Fixation System. 
 
You asked the Plan to pre-approve the StabiLink device. You say that the enrollee is in major pain. You also 
say that the enrollee is losing feeling in their hands, feet and legs, making it difficult to walk. The Plan denied 
your request. The Plan says this is experimental and therefore 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 the StabiLink device. Our reviewer says 
that the requested StabiLink device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this device is experimental. Therefore, the reviewer found that the requested device 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 the StabiLink device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a fusion of spine in lower back (22612) using the StabiLink MIS Spinal Fixation 
System.
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 admission to IRF is required as her current needs 
will not safely be met at a lower level of care, especially given the debility and medical complexities she is 
experiencing following recent surgical procedure. The Plan denied your request. The Plan says based on the 
available information, admission to IRF is not reasonable and necessary, as the enrollee's condition does not 
meet the Medicare rules.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a femur fracture after a fall. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.