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

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on October 1, 2019.
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary and should be paid. The Plan denied your request. The Plan says there is no signed order for this testing and no medical records to support the intent.
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by the treating provider. The order need not be signed but the medical records must demonstrate the intent that the testing be performed. The file contains an unsigned order for a custom drug testing panel. No medical record was provided to demonstrate the intent for the testing in absence of the signature. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on October 1, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says there are 
no new clinical problems or changes that require home health care. 
 
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 physician 
reviewer found that the records do not show that skilled nursing services are required to effectively provide 
treatment to improve the enrollee's condition, or to establish/perform a maintenance program to maintain her 
condition or prevent deterioration. The enrollee has had prior skilled nursing and was educated in disease 
management. There are no complex wounds, new enteral feedings or other skilled nursing needs. The records 
do not show that skilled therapy is needed to effectively provide treatment to improve the enrollee's level of 
function, or to establish/perform a maintenance program. As the enrollee does not require skilled therapy or 
skilled nursing services she does not meet the definition of home health aide services. Therefore, the request for 
home health aide services are not reasonable and necessary to the treatment of the enrollee's illness or injury by 
the skilled professional staff. 
 
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 home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on February 8, 2020. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the Plan requires 
utilization of network providers when possible and available, and requires authorization for certain services. No 
medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been 
documented.   
 
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 an office visit provided on February 8, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for hospital care (99222 and 99232) provided on October 6, 2019 through 
October 8, 2019. 
 
You asked the Plan to pay for the hospital care. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that these services are included in another 
service that has previously been approved and paid. 
 
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. The services at issue were rendered by separate providers with different 
specialties and there is no evidence of a duplicate claim. Additionally, the Plan has not forwarded any 
information regarding each date of service at issue. Therefore, we decided that the Plan has to pay for hospital 
care (99222 and 99232) provided on October 6, 2019 through October 8, 2019.  
 
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 pay for knee orthosis (L1833 and L1297) provided on February 25, 
2020. 
 
You asked the Plan to pay for the knee orthosis. You say that you would like reconsideration because these 
supplies were medically necessary. The Plan denied your request. The Plan says the documentation submitted 
did not indicate that the provider discussed the need for the billed supply code. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. 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 knee orthosis (L1833 and L1297) 
provided on February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on December 10, 2019.
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 a domiciliary or rest home visit provided on December 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on March 11, 2020.
You asked the Plan to pay for the comprehensive periodontal evaluation (D0180). You say that you went to the periodontist for x-rays and an evaluation again. You say that you don't understand why you are getting a bill from the periodontist. 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 pay for the comprehensive periodontal evaluation (D0180) provided on March 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 power operated vehicle. 
 
You asked the Plan to pre-approve a power mobility device. You say that you need a scooter for getting around 
outside. The Plan denied your request. The Plan says you do not meet criteria for a scooter. 
 
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.  
 
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs and your 
condition can be improved by a walker or cane. The item at issue in this appeal is being requested for use 
outside of the home. Although this item may be helpful, neither Medicare nor the Plan cover PMDs for use 
only outside the home. This means that Medicare rules for coverage of a PMD have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Group 1 power operated vehicle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty walker. 
 
You asked the Plan to pre-approve a heavy duty walker. You say that the enrollee needs a walker with an extra 
wide seat. The Plan denied your request. The Plan says the enrollee does not weigh more than 300 pounds. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heavy duty walker have not been met. Therefore, we decided that the Plan does not have to pre-
approve a heavy duty walker.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally invasive lumbar decompression. 
 
You asked the Plan to pre-approve minimally invasive lumbar decompression. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that minimally invasive lumbar decompression is 
only covered for enrollees that are enrolled in a clinical study. 
 
We looked at the file and Medicare rules. Review of the file does not support that the enrollee is enrolled in a 
clinical study. Based on this information, we decided that Medicare rules for coverage of minimally invasive 
lumbar decompression have not been met. Therefore, we decided that the Plan does not have to pre-approve 
minimally invasive lumbar decompression.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-
thigh (78815), for the enrollee. 
 
You asked the Plan to pre-approve the PET scan. You say that the PET scan is medically necessary. The Plan 
denied your request. The Plan says that a PET scan does not add more clinical information and is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 PET scan. Our physician reviewer 
found this should be approved for initial staging per NCD 220.6.17. The service is 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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve positron emission tomography (PET) with concurrently acquired computed tomography (CT) for 
attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815), for the enrollee.  
 
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 provide a Duet Walker/transport chair. 
 
You asked the Plan to provide a Duet Walker/transport chair. You say that you need this walker/transport chair. 
The Plan denied your request. The Plan says there is no physician order or documentation that you have a 
mobility limitation affecting MRADLs. 
 
The Plan follows Medicare rules. Medicare rules say that a walker will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs. 
 
The file does not show you do not have a mobility deficit that impairs your participation in MRADLs. There is 
no physician order for the specialty walker. This means that Medicare rules for coverage of a walker have not 
been met. Therefore, we decided that the Plan does not have to provide a Duet Walker/transport chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve automatic blood pressure monitor (A4670). 
 
You asked the Plan to pre-approve automatic blood pressure monitor. You say that you needed a blood 
pressure monitoring device due to your medical history. The Plan denied your request. The Plan says this is not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve automatic blood pressure monitor (A4670).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. You say that you have been under the care of this 
provider for a serious retina condition and you believe it would be detrimental your health to change doctors at 
this time. The Plan denied your request. The Plan says that in most cases, care the member receives from an 
out-of-network provider will not be covered. The member's Evidence of Coverage states care will be directed 
outside of the primary network only if it has been determined that they cannot provide the necessary care to the 
member. 
 
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 physician's services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI scan. 
 
You asked the Plan to pre-approve an MRI scan. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested MRI 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 an MRI scan. Our reviewer says that 
the documentation does not support that the requested MRI is medically reasonable or necessary. Our physician 
reviewer found the enrollee had a CT on December 28, 2015 and November 17, 2016 that showed stable 
appearance of the lesion. A CT was again performed on February 6, 2018 for abdominal pain revealing normal 
adrenal glands. The provided documentation does not sufficiently support this request. The lack of change in 
lesion size over 12 months or recent new clinical indication for imaging suggests this request for MRI abdomen 
is not medically necessary at this time. Therefore, the enrollee does not meet criteria for the requested services. 
 
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 MRI scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an MRI scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac catheterization to be provided at the out-of-
network facility. 
 
You asked the Plan to pre-approve the cardiac catheterization to be provided at the out-of-network facility. You 
say that your brother passed away at the Plan's in-network facility due to what you believe was a botched 
medical procedure. You say that you will not have your procedure at this facility for your own mental health, 
the best outcome, comfort level and confidence in your cardiologist. The Plan denied your request. The Plan 
says that you must receive your care from a network provider. It is important to know which providers are part 
of our network because, with limited exceptions, while you are a member of our plan you must use network 
providers to get your medical care and services. In addition, you may be limited to providers within your 
Primary Care Provider's (PCP's) and/or Medical Group's network. 
 
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 cardiac 
catheterization to be provided at the out-of-network facility.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injectafer. 
 
You asked the Plan to pre-approve injectafer. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 injectafer. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a past medical history of pulmonary emboli, gastric bypass surgery and 
anemia. Although there is documentation in the records of anemia, there is no documentation of a low iron 
level. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injectafer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter (K0813). 
 
You asked the Plan to pre-approve the power scooter. You say that the power scooter is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a power scooter can be covered when the 
beneficiary has the mental and physical capabilities to safely operate it. 
 
We looked at the file and Medicare rules. The records do not include any documentation of an evaluation to 
determine if the requested power operated vehicle is appropriate for the enrollee or if the enrollee can safely 
operate the scooter in their home. The plan has approved an evaluation but it has not been performed to date. 
Based on this information, we decided that Medicare rules for coverage of the power scooter have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a power scooter (K0813).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial imaging, positron emission tomography 
(PET), perfusion; multiple studies at rest and/or stress (78492), for the enrollee. 
 
You asked the Plan to pre-approve the testing. You say that the testing is medically necessary. The Plan denied 
your request. The Plan says the testing is not 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 testing. Our physician reviewer 
found there are no documented symptoms of angina or angina equivalents. The test is requested for monitoring 
purposes. The medical records provided do not meet the requirements listed in the LCD for Medicare coverage 
for myocardial imaging, positron emission tomography (PET), perfusion; multiple studies at rest and/or stress 
(78492). 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve myocardial imaging, positron emission tomography (PET), perfusion; multiple studies at rest 
and/or stress (78492), for the enrollee.