Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request cannot be approved, because three hours a day of therapy is not needed. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 weakness after a fall. All 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 there is documentation 
of a need for physical and occupational therapy, the documentation does not support a need for intensive 
rehabilitation services. There is not a reasonable expectation that this 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
February 25, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the treating physician ordered this testing to 
determine if there was a more effective therapy to treat the enrollee. The Plan denied your request. The Plan 
says the denial of payment for this testing is correct, because this testing was not billed with the appropriate 
coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with procedure code 
81479 for date of service February 25, 2020.  
 
We looked at the file and Medicare rules. 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 pay for 
comprehensive genomic profile (CGP) testing provided on February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for parenteral nutrition solution (B4185) provided from 
September 13, 2019 to September 19, 2019. 
 
You asked the Plan to pay for parenteral nutrition solution. You say that this was medically necessary. The 
Plan denied your request. The Plan says an itemized shipping invoice and proof of delivery were not submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. A proof of delivery 
was not included in the submitted documentation. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for parenteral nutrition solution (B4185) provided from September 13, 2019 to September 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BLS emergency ambulance (A0428) and ground mileage 
(A0425) provided on November 19, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the ambulance service. You say that this ambulance trip was to a facility for 
rehab. The enrollee needed rehab and there was no other way to move her other than an ambulance. Surely this 
is considered medically necessary. The Plan denied your request. The Plan says non-emergent services with 
non-contracted providers require prior-authorization prior to services being rendered. 
 
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 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. 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. 
Therefore, we decided that the Plan does not have to pay for the BLS emergency ambulance (A0428) and 
ground mileage (A0425) provided on November 19, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided from February 12, 2020 
to February 28, 2020. 
 
You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for outpatient hospital services provided from February 12, 2020 to 
February 28, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a MRI of the cervical spine and a MRI of the lumbar spine. 
 
You asked the Plan to pre-approve the MRIs of the cervical spine and lumbar spine. The Plan denied your 
request. The Plan says that the requested MRI of the spine is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRIs of the cervical spine and 
lumbar spine. Our reviewer says that the MRI of the cervical spine and a MRI of the lumbar spine meet 
coverage criteria. Our physician reviewer found the MRI is being done after extensive alternative therapies 
have been tried, and is medically indicated and reasonable, especially with the radiating nature of pain. 
 
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 MRIs of the cervical spine and lumbar spine have been met. Therefore, we 
decided that the Plan has to pre-approve a MRI of the cervical spine and a MRI of the lumbar spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary complete denture (D5110) and a mandibular 
complete denture (D5120) 
 
You asked the Plan to pay for the maxillary complete denture and mandibular complete denture. You say that 
the enrollee's current dentures are loose and bulky. You also say the enrollee is unable to eat with their current 
dentures. The Plan denied your request. The Plan says these services exceed the maximum count allowed per 
period. 
 
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, maxillary and mandibular dentures are 
each limited to one procedure every five plan years. The record shows that the enrollee received a maxillary 
complete denture (D5110) and a mandibular complete denture (D5120) on March 21, 2018 and the enrollee's 
denture benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for a maxillary 
complete denture (D5110) and a mandibular complete denture (D5120)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ground mileage (A0425) transplant related lodging, meals 
and transportation (S9975) and unlisted special service, procedure or report (99199) provided January 4, 2020 
to January 7, 2020. 
 
You asked the Plan to pay for the travel and lodging expenses. You say that these travel receipts represent your 
post lung transplant doctor visits. The Plan denied your request. The Plan says this request exceeds the limits 
set. The enrollee cannot be reimbursed beyond the transplant timeline. 
 
The Plan must follow Medicare rules. The plan has coverage that exceeds Medicare. The health plan's 
transplant guidelines say that the plan eligible expenses include transportation and Lodging related expenses 
only, for a covered organ transplant at a facility more than 50 miles from the member's home. Reimbursement 
expenses must be received within 365 days (one year) of the covered organ transplant procedure. The records 
show the enrollee had his lung transplant on September 24, 2018. Therefore, the enrollee cannot be reimbursed 
beyond September 24, 2019. Based on this information, we decided that Medicare rules for coverage of the 
travel and lodging expenses have not been met. Therefore, we decided that the Plan does not have to pay for 
ground mileage (A0425) transplant related lodging, meals and transportation (S9975) and unlisted special 
service, procedure or report (99199) provided January 4, 2020 to January 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee is not a candidate for oral bisphosphonates. 
The Plan denied your request. The Plan says the enrollee does not have a history of osteoporotic fracture; or 
previous treatment, contraindication, or intolerance to Zoledronic acid. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our physician reviewer found 
that the enrollee has a history of osteoporosis and Parkinson's disease, complicated by dysphagia. The review 
has determined that the enrollee has not tried and failed the required drug. There is no documentation provided 
indicating the Plan's required drug would likely be less effective, or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
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 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 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 review indicates that the enrollee does not require services at the LTACH that are 
not available at the acute care hospital where she is currently receiving care. There are no services available at 
the LTACH that the enrollee requires that are not available at the health care setting being offered by the health 
plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis 
and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 pay for Knee orthosis (L1851) and suspension sleeve (L2397) 
provided April 14, 2020. 
 
You asked the Plan to pay for the orthoses. You say that you followed the proper protocol in order to receive 
payment and you feel that you were unjustly denied. The Plan denied your request. The Plan says the billed 
service cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for Knee orthosis (L1851) and 
suspension sleeve (L2397) provided April 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on February 6, 2020.
You asked the Plan to pay for the testing services. You say that the physician ordered the testing to determine if
there was a more effective therapy to treat the enrollee. The Plan denied your request. The Plan says coverage
of a comprehensive genomic panel is limited to one test per specimen.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that the testing at issue is not supported in the medical record. The claim provided does not show that
the coding and billing guidance has been followed. Based on this information, we decided that Medicare rules
for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360
testing provided on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 31, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent,
non-urgent services with out-of-network providers require prior authorization.
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
physician's services. We found no exception that would require the Plan to pay for these services. Therefore,
we decided that the Plan does not have to pay for physician's services provided on December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary, as there has been 
temporary pain relief with each of the diagnostic injections. The Plan denied your request. The Plan says the 
medical research has not shown that the use of this kind of treatment improves outcomes. 
 
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 the medical research articles have not shown that sacroiliac joint radiofrequency ablation improves 
outcomes.  It has not shown this treatment to be any better than standard therapies to treat this condition.  
Radiofrequency ablation for sacroiliac joint pain is considered not medically necessary/investigational whether 
performed using traditional, cooled, or pulsed radiofrequency. 
 
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 sacroiliac joint radiofrequency ablation for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not a covered item under Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. 
 
We looked at the file and Medicare rules. The requested power seat elevation system is not covered by 
Medicare or the Plan. Based on this information, we decided that Medicare rules for coverage of a power seat 
elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve a power 
seat elevation system (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 25, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician?s services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on March 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 transmitter for the enrollee. 
 
You asked the Plan to pre-approve the transmitter. You say that this is medically necessary. The Plan denied 
your request. The Plan says the Dexcom G6 is the non-preferred monitor. 
 
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 transmitter. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no evidence that the enrollee has used the health plan?s preferred CGM and been 
unsuccessful with or intolerant of the device.  There is no clear documentation as to why the requested meter is 
necessary over the health plan?s preferred meter.  The documentation does not currently show that the 
requested meter is medically necessary and reasonable. 
 
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 transmitter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Dexcom G6 transmitter for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the enrollee suffers from metatarsalgia and hammertoes which causes the enrollee to have difficulty while walking. You say that the enrollee's treating physician said that the requested custom orthotics would be able to help prevent further damage to the enrollee's feet as well as potentially preventing the need for later surgery if the enrollee's conditions worsen. You stated that the enrollee's physician believes the orthotics will make walking less painful for the enrollee and you asked the Plan to reconsider providing coverage. 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 their condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.