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

 
We decided that the Plan does not have to pre-approve a nuclear stress test. 
 
You asked the Plan to pre-approve the nuclear stress test. You say that you would like reconsideration because 
this service is medically necessary. The Plan denied your request. The Plan says you do not meet coverage 
criteria for this service. 
 
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 nuclear stress test. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you do not have symptoms of chest pain or dyspnea to suggest coronary ischemia and 
no documented electrocardiogram changes concerning for coronary ischemia. Nuclear stress testing in this 
setting has not been shown to improve outcome, even in higher risk patients. 
 
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 nuclear stress test have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a nuclear stress test.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and psychiatric diagnostic evaluation with 
medical services provided on December 19, 2019 to January 16, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit and psychiatric diagnostic evaluation with medical services. You 
say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the 
services received are not a covered benefit. 
 
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 visit and psychiatric diagnostic 
evaluation with medical services provided on December 19, 2019 to January 16, 2020 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 continuous glucose monitor (CGM) and twelve (12) 
months of supplies for the continuous glucose monitoring system. 
 
You asked the Plan to pre-approve a continuous glucose monitor and twelve (12) months of supplies for the 
continuous glucose monitoring system. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that CGMs and supplies are only covered for certain 
indications. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a continuous glucose monitor and twelve (12) months of supplies for the continuous glucose 
monitoring system have not been met. Review of the file shows that the enrollee is on oral agents and uses 
insulin injections once daily. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and twelve (12) months of supplies for the continuous glucose monitoring system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out of network 
(OON) cardiologist. 
 
You asked the Plan to pre-approve an OON office visit. You say that this provider treated your sister. The Plan 
denied your request. The Plan says this service is 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 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 office visit to be provided by an out of network (OON) cardiologist.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after October 28, 
2020. 
 
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that that the enrollee no longer requires daily skilled physical therapy that 
can only be delivered in a SNF. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before October 28, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is 
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pre-approve continued skilled nursing facility (SNF) services after October 28, 2020.  
 
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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the thorax (71260). 
 
You asked the Plan to pre-approve this service. You say that a CT scan of the thorax is medically necessary as 
a follow up to a previous CT Scan of the abdomen/pelvis in which noted a nodular density in the right lung 
base. The Plan denied your request. The Plan says that a CT scan of the thorax is not medically necessary for 
the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 this service. Our reviewer says that a 
CT scan of the thorax is medically necessary. Our physician reviewer found that a CT scan of the chest with 
contrast is indicated for the workup of a solitary nodule. The test is both reasonable and appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the thorax (71260).  
 
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing visits. 
 
You asked the Plan to pre-approve home health nursing services. The Plan denied your request. The Plan says 
further visits are not needed. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health nursing services. Our 
physician reviewer found that the records do not show the skilled nursing services are required to effectively 
provide treatment to improve your condition, or to perform a maintenance program to maintain your condition 
or prevent deterioration. You have had prior skilled nursing for disease and medication management. Your 
conditions are chronic. There is no evidence of complex wound care or other skilled nursing needs. 
Venipuncture alone, without other skilled nursing needs, is not medically necessary. Therefore, the request for 
additional skilled nursing visits is not 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 home health nursing services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health skilled nursing visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. 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 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 review indicates that the enrollee still requires acute hospital level of care 
services and is receiving appropriate care at the present acute care hospital. The enrollee does not require 
services at the LTACH that are not available at the acute care hospital where they are currently receiving care. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vertebroplasty for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the fracture was caused by a high velocity injury. 
 
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 surgery. Our reviewer says that the 
requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is a traumatic lumbar burst fracture with 80% height loss. This is not an osteoporosis fracture. 
Criteria for vertebroplasty not met. 

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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve vertebroplasty for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core build up (D2950), a prefabricated post and core 
in addition to a crown (D2954), and a crown (D2740) for tooth # 10. 
 
You asked the Plan to pre-approve the core build up, pref in addition to a crown, and a crown for tooth # 10. 
The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan says 
prefabricated post and core is not listed as a covered service. The Plan says crowns are covered once per tooth 
every 60 months. The Plan also says that the frequency limit for crowns on tooth # 10 has been reached. 
 
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 core build up and 
prefabricated post and core are not among those covered under this benefit. The Evidence of Coverage clearly 
states that if a dental item or service is not listed in the benefit chart or listed with NC, then it is not covered. 
Additionally, the frequency limit of 1 crown per tooth, per 60 months has been reached. The record shows that 
you received a crown for tooth # 10 on Therefore, we decided that the Plan does not have to pre-approve a core 
build up (D2950), a prefabricated post and core in addition to a crown (D2954), and a crown (D2740) for tooth 
# 10.
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical repair of a hip fracture after a fall. Medical problems are stable. There are no identified problems that 
need inpatient medical management. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it 
does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation 
that you 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray billed with CPT code 71045 for date of service 
July 13, 2020. 
 
You asked the Plan to pay for CPT code 71045. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says the chest x-ray is considered integral to the procedure to 
insert a non-tunneled centrally inserted central venous catheter billed with CPT code 36556. The Plan says that 
an appropriate modifier was not billed with CPT code 71045 that represents the service was separate and 
distinct. 
 
The Plan must follow Medicare rules. The rules say that when a NCCI edit exists between two codes, generally 
only the Column 1 code is payable, unless the modifier indicator for the code is 1 and a clinically appropriate 
modifier is used to bypass the edit.  
 
We looked at the file and Medicare rules. CPT code 71045 is a Column 2 code in relation to code 36556. CPT 
code 71045 was billed with a -26 modifier, which is not a clinically appropriate modifier to allow for separate 
payment. Based on this information, we decided that Medicare rules for coverage of CPT code 71045 have not 
been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray billed with CPT code 
71045 for date of service July 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve irrigation syringe (A4322). 
 
You asked the Plan to pre-approve the irrigation syringe. You say that you would like reconsideration because 
these supplies are necessary for treatment of the member's condition. The Plan denied your request. The Plan 
says Medicare coverage criteria for the syringes is not met. 
 
The Plan must follow Medicare rules. Medicare rules say that when syringes, trays, sterile saline, or water are 
used for routine irrigation, they will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the irrigation syringe have not been met. Specifically, per Medicare, the syringes for routine 
irrigation are a non-covered benefit. Therefore, we decided that the Plan does not have to pre-approve irrigation 
syringe (A4322).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the interspinous process decompression device for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
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 device. Our reviewer says that the 
requested device not considered medically reasonable and necessary in this case. Our physician reviewer found 
the device remains 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the interspinous process decompression device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic shoes (L3215). 
 
You asked the Plan to pre-approve the orthopedic shoes. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says this item is not a covered benefit for your 
condition. 
 
Medicare rules state that supportive devices for the feet (such as orthopedic shoes) 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 
orthopedic shoes may be appropriate for you, neither Medicare nor the Plan provides coverage of orthopedic 
shoes for your condition. Therefore, we decided that the Plan does not have to pre-approve orthopedic shoes 
(L3215).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the medical record is reviewed in its entirety.  
The member has stabilized medically and is ready for discharge from the hospital. The member does not 
require skilled nursing and/or skilled therapy services on a daily basis. The member is medically stable and can 
receive further rehab services at a lower level of care. Although further rehab services would be appropriate to 
improve function, as a practical matter, the daily skilled services can be provided at a lower level of care than a 
skilled nursing facility. The member does not have any parental medication; complex wound care or nutrition 
given via a feeding tube. The member is medically stable without any acute exacerbations of chronic medical 
problems. The member's physical function is at or near their baseline and they can receive services at a lower 
level of care. Admission to a SNF for inpatient skilled rehab services is not 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.