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

 
We decided that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair with multiple 
power options (K0862) and additional items and accessories (codes E0955, E1007, E1012, E1028, E2300, 
E2311, E2313, E2363, E2377, E2608, E2613, and K0108). 
 
You asked the Plan to pre-approve a group 3 heavy duty power wheelchair and additional items and 
accessories. You say that the enrollee is a paraplegia patient, who currently has a group 2 chair, that is only 
capable of tilt/power. You also say that the enrollee's condition has progressed as they have a group 3 
diagnosis, and have the need for a group 3 base that can accommodate multiple power options. The Plan denied 
your request. The Plan says the Medicare criteria are not met for a replacement power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a power mobility device (PMD) will not be covered if 
the patient does not have mobility deficit that impairs their participation in Mobility-Related Activities of Daily 
Living (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. 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 heavy duty power wheelchair 
and additional items and accessories. Our reviewer says that the enrollee does not meet the criteria for 
coverage. Our physician reviewer found the enrollee has had paraplegia since 2018, and has a foot ulcer. The 
enrollee does not have skin breakdown elsewhere on their body. Our 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 heavy duty 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 heavy duty 
power wheelchair with multiple power options (K0862) and additional items and accessories (codes E0955, 
E1007, E1012, E1028, E2300, E2311, E2313, E2363, E2377, E2608, E2613, and K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal ankle foot system, microprocessor-
controlled feature, dorsiflexion and/or plantar flexion control, includes power source (L5973). 
 
You asked the Plan to pre-approve a prosthetic. You say that the prosthetic is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet Medicare criteria for microprocessor foot/ankle 
does not meet Medicare criteria as reasonable and 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 a prosthetic. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the physician documentation does not support that the enrollees activities require a 
microprocessor foot and ankle over a mechanical foot and ankle. The prosthetist is the vendor and recommends 
the microprocessor, but this is not supported in the physician documents. The requested microprocessor foot 
exceeds the enrollees needs. 
 
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 prosthetic have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an endoskeletal ankle foot system, microprocessor-controlled feature, dorsiflexion and/or 
plantar flexion control, includes power source (L5973).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental case management services (D9997) provided on April 
25, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
case management services (D9997) provided on April 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller upgrade with harness and 
electronic connection. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee had a stroke and is 
dependent with activities of daily living. She is able to feed herself after set up. The records support that the 
enrollee has sufficient strength and function in the upper extremities to manage the standard power drives; 
therefore, the requested expandable controller upgrade with harness and electronic connection are not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an expandable controller upgrade with harness and electronic connection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services. 
 
You asked the Plan to pay for physician services. You say that you like how the provider takes care of you 
and your health. The Plan denied your request. The Plan says they will cover services from either network or 
out-of-network providers, as long as the services are covered benefits and are medically necessary. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to provide for physician services. Our reviewer says that the service is not medically necessary. Our physician reviewer found that you are a 55-year-old male with 
joint pain. You received care from a rheumatologist out of network. You were diagnosed 
with familial Mediterranean fever prior to this care. You could have foreseen requiring services for this 
condition. Although the care provided to treat the symptoms related to this genetic condition (no cure) was 
medically necessary, your rheumatologist can reliably treat this condition now that it has been diagnosed. It was not an emergency and could have been delayed until able to schedule with an in-network doctor.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physician services have not been met. Therefore, we decided that the Plan does 
not have to pay for physician services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve T10 kyphoplasty (22513). 
 
You asked the Plan to pre-approve T10 kyphoplasty. 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 both percutaneous vertebroplasty (PVP) and 
percutaneous vertebral augmentation (PVA) will be considered reasonable and necessary for osteoporotic 
conditions when 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 T10 kyphoplasty. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found no trial of fracture bracing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of T10 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve T10 kyphoplasty (22513).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and 2 or more power seating system motors (E2311), a harness (E2313) and an expandable controller (E2377). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says the upgraded electronics are not 
medically necessary. They are necessary when there is a medical need to control power options though 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 wheelchair 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 multiple sclerosis and reduced strength in her wrists, arm and 
shoulders. Per the medical doctor, the enrollee's arms and wrists are 4-/5. The physical therapy notes states 3-
/5. The enrollee's functional status is limited. Per SSA 1862 (a)1 (a), the enrollee has sufficient strength and 
function in upper extremities 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 wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and 2 or more power 
seating system motors (E2311), a harness (E2313) and an expandable controller (E2377).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (36415, 80053, 80164, 82306, 82465, 83036, 
84439, 84443, 84481, 85025, 86140, 87389) provided on August 30, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
as billed. The Plan denied your request. The Plan says that these services are not reimbursable. 
 
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. Specifically, the Plan has not provided a clear reason for denial in this case, and 
this reason has not been supported with evidence and a relevant citation. The Plan states that these services are 
not payable for this provider or place of service, but does not clarify why this is or provide a relevant citation. 
In addition, some codes on this same claim were approved and paid, which brings this argument into question. 
There is a signed physician order and laboratory results for these services. The Plan has not substantiated their 
denial in this case. Therefore, we decided that the Plan has to pay for laboratory services (36415, 80053, 80164, 
82306, 82465, 83036, 84439, 84443, 84481, 85025, 86140, 87389) provided on August 30, 2022.  
 
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 approve the inpatient level of care for a reverse total shoulder 
arthroplasty. 
 
You asked the Plan to approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the inpatient level of care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 approve acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for the inpatient level of care are met.Our 
physician reviewer found the records do not support that the enrollee would be significantly and directly 
threatened if the surgery was performed in a less-intensive setting than the inpatient hospital level of care. The 
records do not support a reasonable expectation that the enrollee will require at least two midnights of inpatient 
hospital care for the planned procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to approve the inpatient level of care for a reverse total shoulder arthroplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) (E0651).

You asked the Plan to pre-approve a PCD. You say that the item is medically necessary. The Plan denied your request. The Plan says the documentation submitted does not provide details on your 4 week trial of conservative therapy or measurements taken before and after trial to show the trial has failed.

The Plan follows Medicare rules. The rules state that the medical necessity determination for a PCD by the treating practitioner must include symptoms and objective findings, including measurements, to establish the severity of the condition.

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 PCD. Our reviewer says that the enrollee does not need this item. Our physician reviewer found the documentation submitted does not provide details on your 4 week trial of conservative therapy or measurements taken before and after trial to show the trial has failed.

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 PCD have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) (E0651).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 occupational therapy visits. 
 
You asked the Plan to pre-approve 5 occupational therapy visits. You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. The Plan denied 
your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have documented, ongoing, home health occupational therapy needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 5 occupational therapy visits.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311). 
 
You asked the Plan to pre-approve an electronic connection. You say that when one power seating 
function/actuator/motor is provided on a power wheelchair, one unit of E2311 is allowed. The Plan denied your 
request. The Plan says that the electronic connection between the power options and controller (E2311) does 
not serve any medical purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an electronic connection. Our reviewer 
says that the electronic connection (E2311) is medically necessary. Our physician reviewer found the electronic 
connection is necessary to operate the group 2 power wheelchair base and the power options via a joystick. Our 
reviewer also found that it is required to operate the power options on a group 2 power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection have been met. Therefore, we decided that the Plan has 
to pre-approve an electronic connection (E2311).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve a bone marrow aspirate. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of 
spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 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 when used as bone graft material. 
 
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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone marrow aspirate (20939).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
you would like the denial for the group 3 power wheelchair to be overturned. The Plan denied your request. 
The Plan says that although there are three approved power options on this wheelchair (tilt, recline and 
elevating leg rests), there is not a medical need to control these power options through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are considered medically reasonable 
and necessary in this case. Our physician reviewer found the expandable controller with harness and electronic 
connection are necessary to operate the group 3 power wheelchair base and the three power options via a 
joystick. Our reviewer also found that these components are required to operate 3 or more power options on a 
group 3 power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, and expandable controller have been met. 
Therefore, we decided that the Plan has to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.