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

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve the semi-electric bed. You say that the semi-electric hospital bed is 
necessary due to your impaired mobility. The Plan denied your request. The Plan says there is not sufficient 
documentation which justifies the need for this equipment based on Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
2. Requires attachments which can only be attached to a hospital bed; AND 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric bed. Our reviewer 
says that the requested hospital bed is not considered reasonable and necessary based on the documentation 
provided. Our physician reviewer found the enrollee is a 75-year-old female with diagnosis of radiculopathy. 
The patient does have chronic pain and impaired functional mobility. The provider is requesting semi-electric 
hospital bed.  There is no documentation to support that these positions cannot be obtained in an ordinary bed. 
the review has determined that  the patient's condition does not require position of the body in ways not feasible 
in an ordinary bed. The patient does not require frequent changes in body position and there is no need for 
immediate changes in body position. The patient's condition does not require special attachments that cannot be 
fixed and used on an ordinary bed. The requested semi-electric hospital bed is not medically necessary for this 
patient. 
 
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 semi-electric bed have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a semi-electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested speech therapy. 
 
You asked the Plan to pre-approve speech therapy. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care or if the care cannot be 
provided with an in-network provider, which requires prior authorization from the plan. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested speech therapy.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve a colonoscopy. You say that you would like approval for these services. The 
Plan denied your request. The Plan says there are in-network providers available for this service. 
 
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 
a colonoscopy to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI to be provided by an out of network (OON) 
provider. 
 
You asked the Plan to pre-approve an MRI. You say that you would like approval to see this provider. The Plan 
denied your request. The Plan says there are in-network providers available. 
 
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 
an MRI to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921) and bone replacement graft 
(D7953). 
 
You asked the Plan to pre-approve gingival irrigation (D4921) and bone replacement graft (D7953). You say 
that the bone graft is medically necessary to replace the bone that was lost to prevent infections of the jawbone. 
You say that the bone graft makes it possible for an implant. The Plan denied your request. The Plan says the 
services are not covered 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 pre-approve 
gingival irrigation (D4921) and bone replacement graft (D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide a Group 2 standard power operated vehicle and accessories. 
 
You asked the Plan to provide a Group 2 standard power operated vehicle and accessories (K0806). You say 
that the enrollee needs a Group 2 standard power operated vehicle and accessories. The Plan denied your 
request. The Plan says this type of PMD has added capabilities that are not needed for use in the home. 
 
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 patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
Neither Medicare nor the Plan cover this type of PMD. Therefore, we decided that the Plan does not have to 
provide a Group 2 standard power operated vehicle and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Electrocardiogram, routine ECG with at least 12-leads; 
interpretation and report only (93010) provided February 3, 2020. 
 
You asked the Plan to pay for the ECG, interpretation and report only. You say that please see attached medical 
records and reprocess for payment, as this is a payable procedure code. The Plan denied your request. The Plan 
says this service was billed incorrectly. The review is already included in the emergency department evaluation 
and management (E/M) payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the billing of code 93010 was submitted inappropriately due to the bundled relationship of services 
within the specialty group. This service has already been paid to another physician. This code can only be 
billed once per day Based on Medicare billing guidelines, this claim cannot be paid as billed. Therefore, we 
decided that the Plan does not have to pay for Electrocardiogram, routine ECG with at least 12-leads; 
interpretation and report only (93010) provided February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient office visit to be provided by an out of 
network (OON) provider to be covered at the in-network level of benefit. 
 
You asked the Plan to pre-approve the outpatient office visit. You say that you would like to go get a second 
opinion and you believe this is the only location that will help you. You cannot afford to go out of network and 
you have already seen all the providers listed as in-network. The Plan denied your request. The Plan says the 
plan has coverage out-of-network benefits. There are 3 in network tertiary centers that are available to provide 
the requested services. If you use an out-of-network provider, your share of the costs for your covered services 
may be higher. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that if you use an out-of-
network provider, your share of the costs for your covered services may be higher. 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 the outpatient office visit to be provided by an out of network (OON) provider to be covered at 
the in-network level of benefit.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve four (4) levels of RFA. We decided that the Plan does not have to 
pre-approve one (1) level of RFA.  
 
You asked the Plan to pre-approve four (4) levels of RFA. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says the enrollee was treated with two injections already. 
 
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 items/services are partially not considered medically reasonable and necessary in this case.  
 
We decided that the Plan has to pre-approve four (4) levels of RFA.  
 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that a maximum of 4 joints RFA may be treated at one session. Only 4 
joints are considered medically reasonable and necessary. Therefore, we decided that the Plan has to pre-
approve four (4) levels of RFA.  
 
We also decided that the Plan does not have to pre-approve one (1) level of RFA. 
 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the 5th level is above utilization limits. Therefore, we decided that 
the Plan does not have to pre-approve one (1) level of RFA. 
 
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 Freestyle Libre continuous glucose monitor. 
 
You asked the Plan to pre-approve continuous glucose monitor. You say that the enrollee has been having 
issues using a blood glucose monitor, and this device is better in terms of monitoring. The Plan denied your 
request. The Plan says the denial of authorization for this device is correct, because the enrollee does not use 
insulin. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic continuous glucose monitors are only 
covered when all 6 of the above-listed clinical criteria have been 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 continuous glucose monitor. Our 
reviewer says that the enrollee does not meet the Medicare criteria for the requested continuous glucose 
monitor. Our physician reviewer found review of the documentation does not support that the enrollee uses 
injectable insulin. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuous glucose monitor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the knee orthosis (L1820). You say that the provider is giving you a bill for 
this item. The Plan denied your request. The Plan says the request for authorization was obtained retroactively, 
making it not a 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 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 
the medical services 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 the inpatient behavioral health stay. 
 
You asked the Plan to pre-approve the inpatient behavioral health stay. You say that the records provided 
should support the necessity of the service in dispute. The Plan denied your request. The Plan says the inpatient 
mental health stay was not medically necessary and the enrollee could have received treatment at the outpatient 
level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the inpatient behavioral health stay. Our 
physician reviewer it did not appear medically necessary and reasonable to have psychiatric care provided at 
the acute inpatient level of care rather than a lower level of care as he did not have dangerousness to self or 
others, perceptual disturbance including delusions, auditory or visual hallucinations. This enrollee did not 
appear to require inpatient mental health treatment as he was not a danger to himself or others and was 
cooperative and compliant. It did not appear that active treatment was taking place. It did not appear that the 
services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. I am 
unable to find an individualized treatment plan however the entire record is not present. It did appear that the 
records were supervised and evaluated by a physician. Based upon review the records provided, for the 
admission of this patient does not meet the criteria for acute inpatient mental health treatment as this patient 
was not shown to be a danger to himself or others but was without agitation or aggression without perceptual 
disturbance including auditory, visual hallucinations or delusions. 
 
 
 
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 inpatient behavioral health stay have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the inpatient behavioral health stay.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that you would like to see this specialist 
because you trust this provider the most. The Plan denied your request. The Plan says there are in-network 
providers available for these services. 
 
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 
a specialist office visit to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lift recliner (E1399). 
 
You asked the Plan to pre-approve the recliner. You say that the chair is medically necessary. The Plan denied 
your request. The Plan says only a seat lift mechanism is eligible for coverage. The chair itself is not primarily 
medical in nature and therefore is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that only lift mechanisms are eligible for payment. 
Chairs are non-covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the recliner have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
lift recliner (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
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 covered for use outside of the home.
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 item at issue in this appeal is for use outside of the home. 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 pre-approve a portable oxygen concentrator
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home oxygen. 
 
You asked the Plan to pre-approve the oxygen. You say that this is medically necessary and has been used 
since November 2019. The Plan denied your request. The Plan says it is unclear why oxygen is needed. 
 
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or 
arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.   
 
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 oxygen. Our reviewer says that the 
requested oxygen is not medically reasonable or necessary. Our physician reviewer found criteria for continued 
coverage of home oxygen are not met. You have been on oxygen, but there is no data to indicate that you need 
it currently. There is one oxygen saturation measurement 7 months ago of 93%, unclear whether breathing 
room air. This does not meet criteria for oxygen need. Oxygen is therefore considered 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 oxygen have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home oxygen.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neurostimulator placement for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medical notes do not show at least 50% improvement with test stimulation. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the medical notes do not show at least 50% improvement with Interstim test stimulation as 
required for coverage. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a neurostimulator placement for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment of root canal obstruction (D3331). 
 
You asked the Plan to pre-approve treatment of root canal obstruction (D3331). You say that you can't pay out 
of pocket for the procedure needed in order to do the root canal. The Plan denied your request. The Plan says 
the service is not a covered benefit. 
 
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 pre-approve 
treatment of root canal obstruction (D3331).