Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve esophagogastroduodenoscopy (43235, 43239). 
 
You asked the Plan to pre-approve esophagogastroduodenoscopy. You say that the enrollee has chronic liver 
disease and cirrhosis; therefore, these services are medically necessary. The Plan denied your request. The Plan 
says these services are not medically necessary based on the documentation provided. 
 
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 esophagogastroduodenoscopy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is insufficient evidence in the provided records to show that the 
enrollee has high risk for advanced liver disease, nor was ultrasound evidence of portal hypertension presented 
to warrant as medically necessary, nor for any other covered indication for the esophagogastroduodenoscopy requested. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of esophagogastroduodenoscopy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve esophagogastroduodenoscopy (43235, 43239).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient neurology visits (96413, 96415) to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve outpatient neurology visits. You say that you have been seeing this provider 
since you were diagnosed with multiple sclerosis. You have tried other medications and none of them work for 
you. The Plan denied your request. The Plan says you must get your care from network providers. The Plan 
also says there are twenty-three in-network neurologists within a 15-mile radius of your home. 
 
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 
outpatient neurology visits (96413, 96415) to be provided by an out-of-network (OON) provider.
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 the admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says the admission to an IRF does not meet criteria. 
 
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 you were admitted for surgical management of a hip fracture. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. You do 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 you 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on January 23, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the enrollee's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 
 The claim was billed with an outpatient hospital facility place of service code. Although this item may be 
helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that 
the Plan does not have to pay for the pneumatic compression device provided on January 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 00811 billed for date of service March 17, 
2023.  
 
You asked the Plan to pay for procedure code 00811. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 00811 is bundled into payment for code 45384. 
 
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, we have confirmed that code 00811 is a column II code to column I code 45384 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 00811 billed for date of service March 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on January 19, 2022. 
 
You asked the Plan to pay for foot orthotics. You say that you disagree with the Plan's denial. 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot orthotics 
provided on January 19, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy services provided on November 
16, 2022. 
 
You asked the Plan to pay for medical nutrition therapy services. The Plan denied your request. The Plan says 
this is not a covered benefit. 
 
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.  
 
The records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for the medical nutrition therapy services provided on November 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to the IRF is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for services in an IRF.  
 
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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pay for supply code A6216. We decided that the Plan does not have to pay for 
supply code A4216.  
 
You asked the Plan to pay for wound care supplies, A4216 and A6216, billed for date of service January 11, 
2023. You say that the items are covered by Medicare. The Plan says that the supplies were used to clean the 
wound. 
 
We decided that the Plan has to pay for supply code A6216.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The file shows that code A6216 was billed with the A1 modifier indicating the item is being used as a primary 
or secondary dressing on a debrided wound. The medical records describe protocols for alternative dressings to 
be used as needed, indicating use as a secondary dressing. Based on this information we decided that the 
Medicare rules for coverage have been met. Therefore, we decided that the Plan has to pay for supply code 
A6216 billed for date of service January 11, 2023.  
 
We also decided that the Plan does not have to pay for supply code A4216. 
 
We looked at the file and the rules. The medical records show that sterile water/saline was used to cleanse the 
wound. Irrigating solutions are not covered in this case. Therefore, we decided that the Plan does not have to 
pay for supply code A4216 billed for date of service January 11, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is needed for use inside and outside the 
home. The Plan denied your request. The Plan says this is not medically necessary. 
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that there are 
still inconsistencies in the documentation provided, and you have a history ambulating with a transtibial 
prosthesis and was approved for a replacement prosthesis. The documentation is insufficient as to why a group 
3 power wheelchair is needed, and why you cannot perform pressure relief. You are noted to have 3/5 motor 
strength in the upper extremities and do not have a history skin breakdown in pressure bearing surfaces. You do 
not have a complex neuromuscular disease and can utilize a group 2 power wheelchair for mobility if needed. 
Therefore, the group 3 power wheelchair with power tilt and power elevating leg rests is 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 the wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261 x 2) and the 
hearing aid tubes (V5267 x 2) purchased on March 6, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are only 
covered when purchased from the Plans select hearing aid provider. However, the hearing aids in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5261 x 2) and the hearing aid tubes (V5267 x 2) purchased on March 6, 
2023.
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 will require a 
multidisciplinary approach to help manage their multiple medically and physically complex issues. The Plan 
denied your request. The Plan says the LTACH services requested do not meet the requirements for approval. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service February 1, 
2022, to February 10, 2022. 
 
You asked the Plan to pay for the billed services. You say that the authorization was not exceeded. The Plan 
denied your request. The Plan says the type of bill is not valid for payment. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that the claim at issue has not been billed with a type of bill code suitable for payment. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. Therefore, 
we decided that the Plan does not have to pay for the home health care billed for dates of service February 1, 
2022, to February 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 percutaneous vertebral augmentation (PVA). 
 
You asked the Plan to pre-approve L1 PVA. You say that the enrollee has a compression fracture and is in 
pain. The Plan denied your request. The Plan says the enrollee does not meet criteria for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that percutaneous vertebral augmentation 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 L1 PVA. Our reviewer says that the 
enrollee does not meet criteria for this procedure. Our physician reviewer found there is no trial of back 
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 L1 PVA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve L1 percutaneous vertebral augmentation (PVA).
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 you are requesting an expedited appeal 
for the denial of an LTACH admission based on medical necessity. The Plan denied your request. The Plan 
says the LTACH services requested do not meet the requirements for approval.  
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care 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 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 cane, includes canes of all materials, adjustable or 
fixed, with tip (E0100) and a bed accessory board, table, or support device, any type (E0315). 
 
You asked the Plan to pre-approve a cane and a bed table. You say that you cannot eat well due to arthritis, 
screws and titanium in both hands due to previous surgery. You also say it is very difficult to eat without a bed 
table as your food falls from your hands. The Plan denied your request. The Plan says the medical notes 
provided by your provider does not indicate that you have a functional deficit with toileting, feeding, dressing, 
grooming, bathing or mobility. The Plan also says the bed table is not a covered benefit with Medicare or your 
Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a 
medical purpose. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a cane and a bed table. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the reviewed documentation does not indicate that you have a functional deficit with 
toileting, feeding, dressing, grooming, bathing or mobility. In addition, the medical notes provided indicate that 
the enrollee's ambulatory status is good. The review has determined that you do not meet criteria for approval 
of a cane. The requested cane is 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 a cane and a bed table have not been met. We also found that the bed table 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 a cane, includes canes of all materials, adjustable or fixed, with tip (E0100) and a bed 
accessory board, table, or support device, any type (E0315).