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

 
We decided that the Plan does not have to pre-approve an MRI of the foot (73718). 
 
You asked the Plan to pre-approve an MRI of the foot. You say that you need an MRI for your provider to 
determine how best to treat you. The Plan denied your request. The Plan says rules for authorization for an 
MRI have not been met. 
 
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 of the foot. Our reviewer says 
that the service is not medically necessary or reasonable. Our physician reviewer found that an X-ray 
demonstrates arthritis of the foot. The most common indication for MR imaging of the foot and ankle is for the 
evaluation of tendon and bone abnormalities, such as osteomyelitis, occult fractures, and partial and complete 
tears of the Achilles, tibialis posterior, and peroneal tendons. The review has determined that there is no 
specific clinical rationale for the requested MRI of the right foot. 
 
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 of the foot have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an MRI of the foot (73718).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intravascular ultrasound followed by an angioplasty 
and stenting. 
 
You asked the Plan to pre-approve an intravascular ultrasound followed by an angioplasty and stenting. You 
say that the requested service is medically necessary for appropriately diagnosing and for guiding the treatment 
of the enrollee. The Plan denied your request. The Plan says there are other options available to the enrollee 
that are acceptable and provide benefit, which have not been exhausted. The Plan says that the request exceeds 
the enrollee's current medical need. 
 
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 an intravascular ultrasound followed by 
an angioplasty and stenting. Our reviewer says that an intravascular ultrasound followed by an angioplasty and 
stenting is not considered medically reasonable and necessary in this case. Our physician reviewer found 
bilateral lower extremity ulceration is documented but not ulcer size or depth.  There did not appear to be any 
recommendation regarding wound care for the ulcers suggesting they might not be substantial.  There was no 
documentation of lower extremity venous duplex studies to determine if there was DVT or significant truncal 
superficial reflux.  With respect to edema, there has been no concerted effort at assessing the response to 
conservative treatment.  It appears that the provider plan went straight to venography with intravascular 
ultrasound and possible endovascular treatment. Our physician reviewer found that less invasive options should 
be evaluated and trialed first. 
 
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 intravascular ultrasound followed by an angioplasty and stenting have not 
been met. Therefore, we decided that the Plan does not have to pre-approve an intravascular ultrasound 
followed by an angioplasty and stenting.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Purewick external catheter system.You asked the Plan to pre-approvethePurewick external catheter system. You say that the enrollee is incontinent of bladder at night and wakes up completely soaked. You say that this puts the enrollee at risk for skin break downs and infections. The enrollee is morbidly obese and is not a candidate for any other incontinence products because they do not fit. You say that the enrollee has used the Purewick device multiple times while in the hospital, and has had great success.The Plan denied your request. The Plan says the item in disputeis not a covered benefit through Medicare or the Plan contract.The Plan must follow Medicare rules. Medicare rules say that PDAC determinations are evidence of the correct coding of an item.A Purewick external catheter system  was reviewed and is correctly coded as A9270. HCPCS code A9270 represents non-covered items or services.Therefore, we decided that the Plan does not have to pre-approvea Purewick external catheter system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve infusion pump supplies. 
 
You asked the Plan to pre-approve the requested supplies. You say that the safest way to administer the 
medication is through the pump. The Plan denied your request. The Plan says the requested medication does 
not require an external infusion pump. 
 
The Plan must follow Medicare rules. Medicare rules say that external infusion pumps are only covered under 
certain medical indications.  
 
The documentation shows that infusion pump supplies were requested to administer Vancomycin, an antibiotic. 
We looked at the file and Medicare rules. The rules do not indicate the requested antibiotic needs to be 
administered by an infusion pump. 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 pre-approve infusion pump supplies.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that SNF care is medically necessary so that the enrollee can be sure his oxygen needs are stable and so that he can resume his activities of daily living.The Plan denied your request. The Plan says the enrollee is not medically stable. The Plan says that the enrollee needs to stay in the hospital until better.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral and inhaled medications, had stable vital signs, used oxygen via a nasal cannula, and continued with diuresis. The enrollee received physical therapy and occupational therapy in the acute hospital.The enrollee was at a supervision to contact guard assist level with functional mobility, including gait to 100 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no further identifiable skilled nursing service needs. While there are identifiable skilled therapy service needs, they are not required on a daily basis. The enrollee does not meet the severity of illness or the intensity of service criteria for an inpatient basis in a SNF 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursingfacility (SNF) services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. You asked the Plan to pre-approve IRF care. You say that the enrollee has made significant progress, and has been deemed to be stable, and ready for transfer to an IRF. The Plan denied your request. The Plan says the medical necessity criteria are not met for an IRF admission. 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 enrollee does not require the intensity of services provided at an IRF. Our reviewer found that specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 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 IRF admission and services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided February 11, 2020. 
 
You asked the Plan to pay for an office visit. You say that the enrollee was not on hospice for the date of 
service at issue. The Plan denied your request. The Plan says the services should be billed to Original 
Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Original 
Medicare continues to pay for services furnished after the revocation or expiration of the enrollee's hospice 
election until the first day of the month after the hospice election has been revoked or terminated. Therefore, 
we decided that the Plan does not have to pay for an office visit (99214) provided February 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific 
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 these services. Our reviewer says that 
the enrollee does not meet the criteria for coverage. Our physician reviewer found the submitted records show 
that the enrollee is taking sliding scale insulin with meals and has a history of low blood sugars. The records do 
not include a log or documentation of how often the enrollee uses the sliding scale insulin or how often insulin 
is adjusted based on readings. The criteria for coverage are not met and the services are not reasonable or 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services from an oral surgeon. 
 
You asked the Plan to pre-approve these services. You say that your tooth is infected and needs to be extracted. 
The Plan denied your request. The Plan says the services are not covered. 
 
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. The request is for services from an oral surgeon. The Plan covers 
supplemental dental benefits from a participating general dentist only. Therefore, we decided that the Plan does 
not have to pre-approve services from an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift for the enrollee. 
 
You asked the Plan to pre-approve a stair lift. You say that the enrollee needs this to get out of the house 
because he cannot use the stairs. The Plan denied your request. The Plan says that this is not a covered benefit 
because a stair lift is not primarily and customarily used to serve a medical purpose and is generally useful to a 
person in the absence of illness or injury. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift 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 stair lift for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe testing services rendered on January 8, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 95861 and 95938 are not supported.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 CPT Code Manual definition of code 95861 is needle electromyography; 2 extremities with or without related paraspinal areas. The definition of code 95938 is short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs.We asked our coderreviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that procedure codes 95861 and 95938 are not supported. Our coderreviewer found the submitted procedure report does not give a sufficient description of the procedure to verify that codes 95861 and 95938 were performed. There is no documentation to support the billing of these codes.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe testing services rendered on January 8, 2020.
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 you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. 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 medically necessary. Our physician reviewer found you were admitted to the hospital 
for heart surgery. Your medical problems are now stable. You have no identified issues that require inpatient 
medical management. You have no complex nursing or rehabilitation needs. You may benefit from further 
therapy but do not require an intensive therapy program 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 pre-approve a pneumatic compression device (PCD) coded E0652 
with full leg sleeve. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an E0652 PCD is covered when specific 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee does not have lymphedema 
extending into the chest or trunk. An assessment on September 24, 2020 states the enrollee has had baseline 
measurements and measurements after conservative therapies but there are no objective detailed measurements 
and anatomic landmarks documented or outcomes of the trial.  The services are not reasonable or medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a pneumatic compression device (PCD) coded E0652 with full leg sleeve.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on February 24, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 10061 is not supported. 
 
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 CPT Code Manual definition of code 10061 is incision and drainage of abscess (eg, carbuncle, 
suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or 
multiple. 
 
We asked our Coder 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 pay for these services. Our reviewer says that 
procedure code 10061 is not supported. Our Coder reviewer found the medical records provided do not include 
documentation of an incision and drainage of abscess, complicated or multiple being performed on February 
24, 2020; therefore, this service cannot be verified. 
 
We looked at this Coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the surgical services rendered on February 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement partial lower denture. 
 
You asked the Plan to pre-approve the partial lower denture. You say that the enrollee is not able to chew 
without dentures and needs new ones. The Plan denied your request. The Plan says the enrollee was covered 
for a lower partial denture which were received in December 2019. As such, coverage for dentures is exhausted 
for five years from that date. 
 
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, dentures are covered only once every 
five years. There is no provision in the contract which allows for coverage of replacement dentures in the event 
of loss, damage, or other issues. Therefore, we decided that the Plan does not have to pre-approve a 
replacement partial lower denture.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation trips. 
 
You asked the Plan to pre-approve routine transportation trips. You say that you need additional transportation 
to attend medical appointments. The Plan denied your request. The Plan says that your request exceeds the 
benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of forty-eight (48) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility visit (99309) provided on 
March 26, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility visit. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was 
not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 subsequent nursing facility visit (99309) 
provided on March 26, 2020, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pedicle soft tissue graft procedure (D4270) provided on 
June 10, 2020. 
 
You asked the Plan to pay for the pedicle soft tissue graft procedure. You say that this procedure is a covered 
benefit. You also say that this procedure is covered both in-network and out-of-network. The Plan denied your 
request. The Plan says this service is not a covered benefit under your dental plan. 
 
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 
pedicle soft tissue graft procedure (D4270) provided on June 10, 2020.