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

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the thoracic and lumbar 
spine. 
 
You asked the Plan to pre-approve the spinal MRI. You say that this MRI is required in order to progress to 
kyphoplasty. The Plan denied your request. The Plan says that there must be a trial of conservative 
management before MRI is warranted. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the spinal MRI. Our reviewer says that 
the requested MRI is found to be medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is a 90-year-old female with a T12 compression fracture with significant pain. Treatment 
plan is to proceed with kyphoplasty. MRI prior to kyphoplasty is performed to determine the precise injury and 
extent of edema in surgical preparation. As such, this imaging is appropriate for this 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 the spinal MRI have been met. Therefore, we decided that the Plan has to pre-
approve magnetic resonance imaging (MRI) of the thoracic and lumbar spine.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cancer Next + RNA insight testing. 
 
You asked the Plan to pre-approve genetic testing. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for this testing is correct, because this 
testing is not covered by the MolDX program. 
 
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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this testing is listed as not covered by the diagnostic exchange for the MolDX program 
administered by the Medicare contractor. Therefore, this request cannot be approved. 
 
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 Cancer Next + RNA insight testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diapers and reusable underpads. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the supplies are becoming costly and 
you cannot afford them on your own as you are on a fixed income. The Plan denied your request. The Plan says 
Medicare criteria for medical supplies do not cover items that can?t be reused.  
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve diapers and reusable underpads.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental, investigational, and unproven. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is considered an experimental/investigational procedure because of the wide variation in efficacy in 
the peer-reviewed literature.  Therefore, the request is considered not medically reasonable or 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac joint radiofrequency ablation.
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 the requested facility is the only one that can 
accommodate the enrollee's weight. The Plan denied your request. The Plan says the guidelines for coverage of 
IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for a tension pneumothorax after a fall. The enrollee's medical conditions are stable. There are no 
medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for 
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There 
is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiation therapy services to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve radiation therapy. You say that the enrollee can only travel a shorter 
distance due to his condition and the condition of his spouse, so his medical needs cannot be met by the in-
network provider. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network 
provider that is within an accessible time and distance from the enrollee's home. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollee's home. The plan contract says that enrollees must use contract providers.  
 
The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located 
within reasonable distance and travel time from the enrollee's home who can provide radiation therapy. Under 
Medicare rules, this means that contract providers are accessible to the enrollee. Therefore, we decided that the 
Plan does not have to pre-approve radiation therapy services to be provided by an out-of-network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services (90832). You say that you would like reconsideration 
because the services rendered were medically necessary and it is the responsibility of the facility to verify 
eligibility. The Plan denied your request. The Plan says utilization of network providers is required unless the 
Plan pre-approves out-of-network services in non-emergent situations. 
 
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 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 periodontal maintenance (D4910), the topical application 
of fluoride varnish (D1206), and the cone beam CT (D0383) provided on August 27, 2020. 
 
You asked the Plan to pay for the dental services. You say that you have been dialysis for 4 years. You say that 
you have experienced deterioration in your jaw bones, specifically. You say that you live a healthy lifestyle. 
You also say that you needed these services. The Plan denied your request. The Plan says the services that you 
received are dental in nature. The Plan also says that routine dental services are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance 
(D4910), the topical application of fluoride varnish (D1206), and the cone beam CT (D0383) provided on 
August 27, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF rehabilitation services provided from March 23, 2020, 
through March 31, 2020. 
 
You asked the Plan to pay for the SNF rehabilitation services. The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the member?s terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on March 23, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for skilled nursing 
facility (SNF) rehabilitation services provided from March 23, 2020, through March 31, 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 rehabilitation is needed to improve the enrollee's 
condition and regain functionality. You say that the enrollee has had multiple emergency room visits and 
hospitalizations since his surgery in October. You say that the enrollee has not improved under his family's 
care. The Plan denied your request. The Plan says the requirements for coverage of IRF care have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for coronary artery bypass grafting, followed by a stay in skilled nursing of about 3 weeks. He 
had another acute hospitalization for pneumonia and a week stay in skilled nursing. He is now living at home 
and remains weak. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient 
admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record documents a need for physical and occupational therapy, it does not 
document a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray and computed tomography angiography 
(CTA) of the chest rendered on August 5, 2020 and August 6, 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 the claims were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that inpatient services must be billed with POS code 
21. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the 
dates of service at issue. The services were incorrectly billed with POS code 22 for an outpatient hospital. 
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 chest x-ray and computed tomography 
angiography (CTA) of the chest rendered on August 5, 2020 and August 6, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services rendered on July 9, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid 
for Medicare purposes. The rules say that any diagnosis code not listed as supporting medical necessity of code 
95938 does not support medical necessity. 
 
The services at issue are testing services billed with codes 95941 and 95938. Code 95941 has a status indicator 
of I and is not valid for Medicare purposes. Code 95938 was billed with diagnosis code M46.22. This diagnosis 
code is not listed as supporting medical necessity. Therefore, we decided that the Plan does not have to pay for 
the testing services rendered on July 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance ride provided on October 
10, 2020. 
 
You asked the Plan to waive the copayment for the ambulance ride. You say that it is your understanding that 
there would be no charge for Covid-related services.  The Plan denied your request. The Plan says you have 
been charged the correct cost sharing amount. 
 
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 a $300 
copayment per one-way trip for emergency ambulance services and non-emergency ambulance services.  
 
You have been asked to pay a $300 copayment for the ambulance ride. The ambulance ride falls within the 
?Ambulance services? 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 the 
ambulance ride provided on October 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on October 2, 2020. 
 
You asked the Plan to pay for the wound care. The Plan denied your request. The Plan says non-emergent, non-
urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for wound care provided on October 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical and bitewing x-rays rendered on July 28, 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 the periapical x-rays exceed the benefit limit and the bitewing x-rays are not separately 
payable. 
 
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. The Plan covers periapical x-
rays once per calendar year. 
 
We looked at the file and the Plan?s rules. The file shows that you had five periapical x-rays on July 28, 2020. 
The Plan reimbursed you for one periapical x-ray. Further periapical x-rays are not covered by your 
supplemental dental benefit or your medical benefit. 
 
The file shows that you received bitewing x-rays on July 28, 2020. The provider billed codes D0270 and 
D0272 for these services. Code D0272 is the primary procedure code and D0270 is included with this 
procedure code and cannot be separately paid.  
 
Based on this information, we decided that the Plan's rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the periapical and bitewing x-rays rendered on 
July 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no notes of any ongoing health issues that require close monitoring by a 
physician. 
 
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 you do not require the intensity of services provided at an IRF.  Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
care needs can be met at a lower level of care (ex. SNF/SAR). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aquatic therapy. 
 
You asked the Plan to pre-approve the aquatic therapy. You say that you would like reconsideration because 
this therapy is necessary to strengthen your leg. The Plan denied your request. The Plan says aquatic therapy 
does not have any value over land therapy in this case. 
 
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 aquatic therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no evidence on the treating medical provider's progress notes that indicates 
you are unable to participate in land based therapy or require aquatic therapy for your condition over land 
based therapy. 
 
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 aquatic therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve aquatic therapy.