Persius/hicric huggingface dataset:
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for pelvic fractures after a fall. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
does document 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 this patient 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 IRF admission and 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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided the complexity of the patient's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The patient does require physical therapy and occupational therapy services but 
based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy 
program. Based on the medical records provided there is no documentation that the patient requires the 
intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled 
nursing facility level appears to be more appropriate in this case. 
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve knee arthroplasty. 
 
You asked the Plan to pre-approve knee arthroplasty. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says that the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 knee arthroplasty. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found you present with complaints of severe right knee pain with swelling. Functional limitations are 
noted in activities of daily living. Clinical exam findings are consistent with radiographic and imaging evidence 
of tricompartmental right knee osteoarthritis. You have failed long-term reasonable and/or comprehensive 
conservative treatment. Current evidence based medical guideline criteria have been met to support this 
request. There is evidence of severe symptoms of knee osteoarthritis, limited mobility, body mass index less 
than 40, failure of conservative treatment, and imaging evidence of significant osteoarthritis. Therefore, you 
have a diagnosis, condition and symptoms that meet Medicare criteria for total knee arthroplasty. Total knee 
arthroplasty would be considered the standard of care and medically reasonable and necessary for treatment of 
the your medical condition. 
 
Review of the file shows that the plan uses Local Coverage Determination (LCD) L36039 to support their 
denial. However, LCD L36039 is not valid for your (the enrollee) home state. Therefore, we 
cannot use LCD L36039 to substantiate our decision. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of knee arthroplasty have been met. Therefore, we decided that the Plan has to pre-
approve knee arthroplasty.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telephone evaluation and management eleven (11) to 
twenty (20) minutes (99442) provided on June 4, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for telephone evaluation. 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 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 telephone evaluation and management eleven 
(11) to twenty (20) minutes (99442) provided on June 4, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the shoulder. 
 
You asked the Plan to pre-approve MRI of the shoulder. You say that the MRI is medically necessary. The Plan 
denied your request. The Plan says Medicare criteria for coverage of the MRI are not 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 MRI of the shoulder. Our reviewer says 
that MRI of the shoulder is not medically necessary at this time. Our physician reviewer found there is no 
documentation of a recent trial and failure of physical therapy for shoulder pain. Medicare criteria for coverage 
of the MRI are not met in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI of the shoulder have not been met. Therefore, we decided that the Plan 
does not have to pre-approve magnetic resonance imaging (MRI) of the shoulder.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on July 
18, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for domiciliary visit. You say that medically necessary services were rendered in 
good faith. 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 domiciliary or rest home visit (99336) 
provided on July 18, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (coded E2300), self-
leveling cup holder (K0108), USB charger (K0108), and an expandable controller with related hardware and 
electrical connections (E2377, E2313, E2311) for use with an approved power wheelchair (PWC). 
 
You asked the Plan to pre-approve the requested PWC components/accessories. You say that the requested 
items should be covered. The Plan denied your request. The Plan says all items other than those that are not 
considered medical in nature or that are not medically necessary have been approved. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that, to be covered as DME, items must be primarily medical in 
nature.  
 
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 requested PWC 
components/accessories. Our reviewer says that the requested expandable controller and related items are not 
shown to be medically reasonable and necessary in this case. Our physician reviewer found there is no 
documentation in the record to support that the individual switches for the power seating features cannot be 
accessed. As such, it is not medically necessary to control these from the main controller. 
 
The requested power seating system is specifically excluded from coverage as it is not found to be primarily 
medical in nature. In addition, the requested cup holder and USB charger do not serve medical purpose.  
 
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 requested PWC components/accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation feature (coded E2300), self-leveling 
cup holder (K0108), USB charger (K0108), and an expandable controller with related hardware and electrical 
connections (E2377, E2313, E2311) for use with an approved power wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right foot orthosis. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no diabetic foot disease or brace on the right leg. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve a right foot orthosis.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ALIMTA (pemetrexed) injections. 
 
You asked the Plan to pre-approve the ALIMTA. You say that there are very few salvage therapies available 
for the enrollee's condition. This treatment has shown some evidence of being effective and should be allowed. 
The Plan denied your request. The Plan says the enrollee does not have a diagnosis for which this may be 
covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 ALIMTA. Our reviewer says that 
the requested treatment with ALIMTA is not considered medically reasonable and necessary. Our physician 
reviewer found this review relates to a request for ALIMTA to be given with Gemcitabine to treat a 74-year-
old man with metastatic extra-mammary Paget's disease. The drug is not FDA approved for Paget's disease. 
The drug is not supported in any of the CMS approved compendia for this use. The prescriber submitted two 
case reports from non-CMS approved journals using the drug as monotherapy. These do not reflect the 
enrollee's clinical situation. This reviewer did not find any supporting articles meeting CMS criteria in a 
PubMed search. 
  
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 ALIMTA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ALIMTA (pemetrexed) injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveprogressive lenses, lens tints, and anti-reflective coating.You asked the Plan to pre-approvethese 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 progressive lenses and lens tints are non-covered and anti-reflective coating is covered only when medically necessary.We looked at the file and Medicare rules. The requested progressive lenses and lens tints are not covered by Medicare. The file shows that the anti-reflective coating is being requested as a convenience item and not for a medical reason and is therefore not covered.Therefore, we decided that the Plan does not have to pre-approveprogressive lenses, lens tints, and anti-reflective coating.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for nuclear medicine provided by a 
participating provider on July 21, 2020. 
 
You asked the Plan to waive the copayment for diagnostic radiology services. You say that this copayment is 
too high. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $350 
copayment for outpatient diagnostic test/diagnostic radiology services/outpatient hospital.  
 
You have been asked to pay a $350 copayment for diagnostic radiology services. Diagnostic radiology services 
fall within the outpatient diagnostic test/diagnostic radiology services/outpatient hospital 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 nuclear medicine provided by a participating provider on 
July 21, 2020.
Appeal type: Lab
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. 
 
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.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on May 28, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the provider told you that you 
wouldn't be billed for this. The Plan denied your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay $325 per day for Medicare-covered diagnostic radiology services.  
 
The enrollee has been asked to pay a $325 copayment for the CT scan. The CT scan falls within the "Outpatient 
diagnostic tests and therapeutic services and supplies" benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for the CT scan provided on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient office or other outpatient visit (99214) 
provided by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient 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 established patient office or other outpatient 
visit (99214) provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept intraosseous nerve ablation procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you strongly believe that the Intracept 
procedure is medically necessary and the most effective treatment for the enrollee at this time. The Plan denied 
your request. The Plan says this procedure is considered experimental, investigational and not an accepted 
standards of medical practice for the diagnosis or treatment of back pain. 
 
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 Intracept procedure.

 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept intraosseous nerve ablation procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen concentrator, single delivery port (E1390) and 
portable gaseous oxygen system (E0431) provided on March 6, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the oxygen supplies. You say that please review and reprocess all claims for 
payment. Claims were denied in error for no authorization/referral. You have an authorization from the PCP. 
The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network 
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 
providers require prior authorization before services being rendered. 
 
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 oxygen concentrator, single delivery port (E1390) 
and portable gaseous oxygen system (E0431) provided on March 6, 2020 by an out of network (OON) 
provider.