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

 
We decided that the Plan does not have to pre-approve a transport chair. 
 
You asked the Plan to pre-approve these services. You say that you need the chair for transport to 
appointments. The Plan denied your request. The Plan says the services are not covered. 
 
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 transport chair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nucynta ER. 
 
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 self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nucynta ER.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you require the raised toilet seat because 
you have trouble with your legs. The Plan denied your request. The Plan says a raised toilet seat is considered a 
convenience item for hygiene purposes and is not primarily medical in nature. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat 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 raised toilet seat.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation - diagnostic service (D9310) and surgical 
placement of implant body (D6010) provided on July 23, 2020, to September 3, 2020. 
 
You asked the Plan to pay for the consultation - diagnostic service and surgical placement of implant body. 
You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. 
The Plan says these services are not covered under your benefit 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 
consultation - diagnostic service (D9310) and surgical placement of implant body (D6010) provided on July 
23, 2020, to September 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted chemistry procedure (84999) provided on 
February 14, 2020. 
 
You asked the Plan to pay for the unlisted chemistry procedure. You say that you would like reconsideration 
because this service was reported correctly. The Plan denied your request. The Plan says Medicare requires a 
narrative explanation of unlisted CPT codes on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that when billing for unlisted laboratory tests using a NOC code, this field MUST include the 
specific name of the laboratory test(s) and/or a short descriptor of the test(s). 
 
We find that CPT code 84999 is not supported in the record. Specifically, the claim includes a NOC code and 
does not include the specific name of the laboratory test or a short descriptor of the test. Based on this 
information, we decided that Medicare rules for coverage of the unlisted chemistry procedure have not been 
met. Therefore, we decided that the Plan does not have to pay for the unlisted chemistry procedure (84999) 
provided on February 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entresto Tab 24-26mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Entresto Tab 24-26mg for 
the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) head or brain 
(70470) provided September 16, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the doctor ordered the tests and 
thought it was necessary. The Plan denied your request. The Plan says the claim was processed correctly and 
the correct copayment was applied per the Evidence of Coverage. 
 
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 you must pay $240 
copay for CT scans performed in an outpatient hospital facility or free standing facility for Outpatient 
diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $173.31 for the CT scan. The copayment is less than the contractual rate and you 
are being held responsible for the lesser amount. The CT scan falls within the Outpatient diagnostic tests and 
therapeutic services and supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
computed tomography (CT) head or brain (70470) provided September 16, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve hyperbaric oxygen therapy (HBO therapy). 
 
You asked the Plan to pre-approve HBO therapy. You say that the enrollee's toe has gangrene. The Plan denied 
your request. The Plan says that the denial of authorization for this service is correct, because the enrollee has 
not failed standard wound care.  
 
The Plan follows Medicare rules. Medicare rules state that hyperbaric oxygen therapy (HBO therapy) is only 
covered for certain clinical indications. 
 
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 HBO therapy. Our reviewer says that 
the enrollee meets the Medicare criteria for HBO therapy. Our physician reviewer found in this case, there is 
documentation of failure of outpatient wound care or surgical debridement. The enrollee has also been treated 
with oral antibiotics. The enrollee has a condition indicated for coverage. The records show that the enrollee 
has failed 30 days of standard wound care. The requested HBO therapy is medically reasonable and necessary 
to treat 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 HBO therapy have been met. Therefore, we decided that the Plan has to pre-
approve hyperbaric oxygen therapy (HBO therapy).  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient rehabilitation facility services provided from September 
26, 2019 to October 20, 2019. 
 
You asked the Plan to pay for the inpatient rehabilitation facility services. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says that the services provided were billed 
incorrectly. 
 
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. Review of the file shows that the Plan states that the services were billed 
incorrectly and that a corrected claim is needed in order to process the claim. However, the records submitted 
do not include documentation on what was billed incorrectly. There is no reasoning as to why this claim cannot 
be processed as submitted. The Plan has not substantiated their denial. Therefore, we decided that the Plan has 
to pay for the inpatient rehabilitation facility services provided from September 26, 2019 to October 20, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulicity. 
 
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 self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trulicity.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on July 11, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until October 8, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the services provided on July 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a CardioMEMS system. 
 
You asked the Plan to pre-approve CardioMEMS. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies 
have not proven that this is helpful for the enrollee's condition. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further 
clinical study is needed to determine the efficacy and safety of this device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of a CardioMEMS system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 1, 2020, by a 
non-participating provider. 
 
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 the services were rendered by a non-participating provider without 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 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 medical services provided on September 1, 
2020, by a non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a folding power scooter for the enrollee. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no physician's order, which is required. 
 
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.  
 
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 scooter. Our reviewer says that the 
requested scooter is not medically necessary. Our physician reviewer found the documentation is not clear that 
the enrollee would be able to safely operate the requested scooter in the home. It is not clear that your mobility 
deficit impairs participation in MRADLs in the home. Your mobility deficit is helped by a walker. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a folding power scooter for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient mental health facility for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says there are other services that may be available as part of the mental health benefit. 
 
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 admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found based upon a 
review of the records provided, it was not expected that this enrollee would improve in a reasonable period of 
time for the dates in question, as she did not have suicidal or homicidal ideation notes. The enrollee denied any 
auditory or visual hallucinations. The enrollee was non-compliant with treatment and was found to be quite 
irritable. 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 she did not show dangerousness to self. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to an inpatient mental health facility for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory testing provided on September 
1, 2020. 
 
You asked the Plan to waive the copayment for lab test. You say that this lab test was performed as part of your 
yearly physical, so you should not be charged a copayment for this. The Plan denied your request. The Plan 
says the copayment amount you are being charged is correct. 
 
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 you must pay $10 
copayment $10 copayment, per day, for lab testing. The preventive medicine visit you received was approved 
by the Plan with no cost-share for you; however, this lab testing is considered a separate service from that visit 
and the lab copayment does apply to this claim. 
 
You have been asked to pay $10 copayment for lab test. Lab test falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for laboratory testing provided on September 1, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99281) provided July 10, 2020. 
 
You asked the Plan to pay for the emergency room services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the claim was not submitted correctly. 
 
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 CPT code 99281 is not supported in the medical record. Specifically, an invalid revenue code was 
used for the Type of Bill submitted. Based on this information, we decided that Medicare rules for coverage of 
the emergency room services have not been met. Therefore, we decided that the Plan does not have to pay for 
emergency room services (99281) provided July 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on July 22, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on July 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA genetic testing. 
 
You asked the Plan to pre-approve genetic testing. You say that this testing will be beneficial in helping you 
decide if you should have a bilateral mastectomy or lumpectomy. The Plan denied your request. The Plan says 
the denial of authorization for this testing is correct, because this testing is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that BRCA testing is only covered under certain clinical 
conditions. 
 
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 genetic testing. Our reviewer says that 
you do not meet the Medicare criteria for the requested genetic testing. Our physician reviewer found 
guidelines do not support BRCA testing for your current clinical scenario based on your age and lack of 
positive BRCA close family. 
 
We looked at this physician's review, 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 pre-approve BRCA genetic testing.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Superion procedure. You say that the enrollee has spinal stenosis which 
is contributing to disability and lost productivity. The Plan denied your request. The Plan says this is 
considered an experimental procedure at this time. 
 
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 Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy. 
 
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 Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a Superion interspinous spacer.