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

 
We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan (78815). 
 
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 coverage criteria has not been met. 
 
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 reviewer says that 
the requested PET scan is not medically necessary. Our physician reviewer found the enrollee has 
lymphadenopathy and had a PET scan in March, 2020. with a negative biopsy in May 2020. A follow-up PET 
scan is not necessary as a CT scan of the chest could determine if nodes are bigger, followed by biopsy if 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Positron Emission Tomography (PET) scan (78815).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950). 
 
You asked the Plan to pre-approve core buildup (D2950). You say that a restoration will not be retentive due to 
the extent of missing tooth structure. You say that core buildup and crowns are needed to protect the teeth from 
further damage. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildup (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home visit for the evaluation and management of an established patient, typically, 60 minutes are spent face-to-face with the patient and/or family (CPT Code 99350) provided on September 26, 2019. You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the billed code 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. 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 pay for the services. Our physician reviewer found the documentation submitted was reviewed, and does not fit criteria. The documentation submitted did not include a home visit from a physician or other qualified health professional.  The documentation is for a in home nursing visit.  A physician or other qualified health care professional must be present in the home in order to report CPT 99350. The documentation does not support the service billed. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for home visit for the evaluation and management of an established patient, typically, 60 minutes are spent face-to-face with the patient and/or family (CPT Code 99350) provided on September 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 very heavy duty power operated vehicle 
(K0802). 
 
You asked the Plan to pre-approve a Group 1 very heavy duty power operated vehicle. You say that that you 
cannot carry out ADL's without assistance. The Plan denied your request. The Plan says that you do not meet 
the weight requirement for a very heavy duty scooter. 
 
The Plan must follow Medicare rules. Medicare rules say that you must weigh between 428 and 600 pounds for 
a very heavy duty POV. 
 
We looked at the file and Medicare rules. The file indicates you do not weigh between 428 and 600 pounds. 
Based on this information, we decided that Medicare rules for coverage of a Group 1 very heavy duty power 
operated vehicle have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 
1 very heavy duty power operated vehicle (K0802).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) provided 
February 4, 2020. 
 
You asked the Plan to pay for the hospital discharge day management. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the documentation does not support the 
services billed. 
 
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 99239 is Hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the record does not show 
that more than 30 minutes was spent on this service. Based on this information, we decided that Medicare rules 
for coverage of the hospital discharge day management have not been met. Therefore, we decided that the Plan 
does not have to pay for hospital discharge day management (99239) provided February 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies suchas physical and occupational therapy but the documentation does not support that your functional status requires or can tolerate an intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meetMedicare criteria for IRF care.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis addition piece (L2385) provided to the 
enrollee on April 9, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says there is no itemized billing/shipping invoice to verify the services billed. 
 
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 a proof of delivery to support medical necessity for the supplies provided in this 
case. There is no itemized billing/shipping invoice to verify the services billed. 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 a knee orthosis addition piece (L2385) provided to the enrollee on April 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says these services are 
available in-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 medical 
services to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable CPAP machine. 
 
You asked the Plan to pre-approve the machine. You say that this is medically necessary. The Plan denied your 
request. The Plan says this would be a duplicate CPAP. 
 
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 machine. Our reviewer says that the 
requested machine is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee was noted to have an existing BiPAP machine. Documentation supports the enrollee 
requested a travel unit.  The documentation does not indicate issues related to the current unit. The 
documentation does not outline a clear need for a travel machine.  The request is not supported as medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the machine have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable CPAP machine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair transport accessory (K0108). 
 
You asked the Plan to pre-approve the wheelchair transport accessory. You say that the transport accessory is 
medically necessary. The Plan denied your request. The Plan says this item is 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 wheelchair transport accessory (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office or outpatient visit (99204) provided on March 12, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that telemedicine does not require prior authorization. The 
Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network provider. 
 
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 office or outpatient visit (99204) provided on 
March 12, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tumor imaging, positron emission tomography provided on 
February 7, 2020. 
 
You asked the Plan to pay for the tumor imaging, positron emission tomography. The Plan denied your request. 
The Plan says that 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 tumor imaging, positron emission tomography provided on 
February 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 4, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you only 
have benefits for in-network providers. In-network services will be covered as long as the services are covered 
benefits and are medically necessary. You may only receive services from out-of-network providers for 
emergency or out of area urgently needed services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
physician?s services. 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 physician's services provided on March 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that the requested drug will allow the enrollee the best 
quality of life. You also say that the requested drug is medically necessary. The Plan denied your request. The 
Plan says the accepted use of this drug for your illness requires you do not have low iron. The Plan also says 
that the requested drug is not medically necessary. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Aranesp. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found the plan offers an effective drug 
Retacrit. The reviewer found that the requested drug, Aranesp, is only indicated if Retacrit has been failed as a 
therapy. The reviewer found that there is no evidence that the enrollee has tried and failed Retacrit. Therefore, 
the reviewer found that the requested drug is not medically reasonable and 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 Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve the medical services. You say that the services are necessary. The Plan 
denied your request. The Plan says there are in-network orthopedic surgeons with the expertise you need. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the clinical documentation provided 
supports the need for LTACH care. The Plan denied your request. The Plan says the guidelines for coverage 
have not been met. The Plan says that the services needed could be provided in another setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the current acute care hospital with pneumonia, sepsis, 
acute respiratory failure, a large necrotic pressure wound in the sacral area and other left hip wound as well as 
left foot wound. He was treated with BiPAP, PEG tube feeds, rectal tube, antibiotics, and wound care. The 
family declined surgical debridement of the wounds. Recent notes suggest he is gradually improving. The 
enrollee appears to be more stable and requires less than an additional 25 days of acute care services based on 
the recent notes. The enrollee does not require services at the LTACH that are not already available at the 
current setting. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Therefore, this request for LTACH services will be considered not medically 
necessary at this time. Since there is no benefit to transferring to LTACH, transfer to a lower level of care may 
be considered once further improvement is noted. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided from April 14, 2020, through April 19, 2020. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 14, 2020 to April 19, 2020. The 
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays 
for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services 
provided from April 14, 2020, through April 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the excision of lesion of eyelid (67840) provided on July 13, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for removal of eyelid lesion. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network provider. 
 
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 excision of lesion of eyelid (67840) provided 
on July 13, 2020 by an out of network (OON) provider.