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

We decided that the Plan does not have to pre-approve Myocardial Perfusion Imaging (78451). 
 
You asked the Plan to pre-approve the Myocardial Perfusion Imaging. You say that the imaging is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Myocardial Perfusion Imaging is non-covered when 
used as a screening test. 
 
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 Myocardial Perfusion Imaging. Our 
reviewer says that the requested imaging is not medically necessary. Our physician reviewer found the enrollee 
has increased coronary risk but no documented chest pain, dyspnea, or ECG changes. In this circumstance the 
documentation does not support screening stress testing. Screening stress testing, even in  high risk patients has 
not been shown to improve outcome. 
 
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 Myocardial Perfusion Imaging have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Myocardial Perfusion Imaging (78451).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic care (CPT 97012, CPT 97110) provided 
from December 2, 2019, to December 6, 2019. 
 
You asked the Plan to pay for the chiropractic care. The Plan denied your request. The Plan says these services 
are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the chiropractic care (CPT 97012, CPT 97110) provided from December 
2, 2019, to December 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be received in other settings, for example: a skilled nursing facility, 
home with home health services, or home with outpatient therapy. 
 
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 enrollee's nursing, medical and rehabilitation needs do not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require an 
intensive inpatient rehabilitation therapy program. There is concern that the enrollee would not be able to fully 
participate in the requested program. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new BiPAP device and accessories for the enrollee. 
 
You asked the Plan to pre-approve the new device. You say that this is medically necessary. The Plan denied 
your request. The Plan says a positive airway pressure (PAP) device can be replaced during the five-year 
reasonable useful lifetime (RUL) of the device when there is documentation of loss, theft, or irreparable 
damage due to a specific incident. 
 
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 new device. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a replacement BiPAP device and associated supplies is being requested, within the 5-yr 
expected life of the device. The medical records do not indicate that the device was evaluated and found to be 
non-reparable.  If the device is defective and beyond repair, then replacement is reasonable and medically 
necessary. Otherwise replacement is considered 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 the new device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a new BiPAP device and accessories for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the 
enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's needs can be met at an alternate level of care. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for continued SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the brain (70551). 
 
You asked the Plan to pre-approve an MRI of the brain. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
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 an MRI of the brain. Our reviewer says 
that the services are medically necessary. Our physician reviewer found this enrollee not only has tremors and 
imbalance but also has mitral valvular heart disease as well as atrial fibrillation. While the enrollee's 
neurological exam was normal, her clinical history including valvular heart disease qualifies her for an MRI of 
the brain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the brain have been met. Therefore, we decided that the Plan has to 
pre-approve a magnetic resonance imaging (MRI) of the brain (70551).  
 
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 waive the $20 copayment charged for to the enrollee for specialist 
services provided on June 23, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment was charged based on the services provided and the 
Plan contract agreement. 
 
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 $20 
copayment for specialist services. 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 $20 copayment charged for to the enrollee for 
specialist services provided on June 23, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve behavioral health psychological testing. 
 
You asked the Plan to pre-approve behavioral health psychological testing. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 behavioral health psychological testing. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee suffers from vascular dementia and epilepsy. The enrollee 
was given 5 units on 60-minute testing codes and 5 units on 30-minute testing codes that did not require 
approval. Based on review the records provided, this enrollee has had difficulty with depression. The 
documentation shows that the enrollee has not had an evaluation by a psychologist or psychiatrist and the 
enrollee has not had a diagnostic evaluation. Criteria states that this testing is intended to diagnose and 
characterize the neurocognitive effects of medical disorders that impinge directly on or indirectly on the brain 
including detection of neurologic disease based on quantitative assessment of neurocognitive abilities, 
differential diagnosis between psychogenic and neurogenic syndromes, delineation of neurocognitive effects of 
central nervous system disorders, neurocognitive monitoring of recovery or progression of central nervous 
system disorders or assessment of neurocognitive function for the formulation of rehabilitation and/or 
management strategies among individuals with neuropsychiatric disorders, this patient in does not meet the 
criteria for medical necessary or reasonable to have neuropsychological testing as outlined as the enrollee has 
not had a preliminary evaluation by a psychologist, psychiatrist or diagnostic evaluation. It is believed that the 
results would be confounded due to the excessive amount of alcohol which is consumed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of behavioral health psychological testing have not been met. Therefore, we 
decided that the Plan does not have to pre-approve behavioral health psychological testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiation therapy. 
 
You asked the Plan to pre-approve radiation therapy. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that IMRT is covered under certain circumstances. 
 
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 radiation therapy. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found given that the treatment was not 
definitive, the dose used to treat the primary esophageal cancer is unlikely to afford long-term tumor control, 
making the need for radiation to treat oligometastases somewhat dubious. Generally, metastasis-directed 
radiotherapy (SBRT, IMRT) is considered in patients with oligometastases who have received standard of care 
systemic therapy. Delivering concurrent systemic therapy (as offered to this enrollee) and stereotactic body 
radiation therapy (SBRT) or IMRT for metastatic disease is not standard of care. The treating physicians offer 
no rationale for why this would be done. There is no literature or citations offered to support this 
recommendation of metastasis-directed radiotherapy and chemotherapy. As the treatment offered falls outside 
accepted standards of care, and no plausible justification is offered for such treatment, medical necessity has 
not been established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiation therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve the semi-electric hospital bed. You say that the bed is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that hospital beds are covered when 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 semi-electric hospital bed. Our 
reviewer says that the bed is not medically necessary. Our physician reviewer found the records do not support 
the need for immediate or frequent change of body position as required by coverage criteria. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care for the enrollee. 
 
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's needs can be met at a lower level of care. 
 
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 SNF 
care is medically reasonable and necessary for the enrollee in this case. The enrollee does have documented 
skilled nursing needs. The enrollee requires daily dressing care to a stage IV sacral wound. The enrollee does 
not have documented skilled therapy needs. Daily skilled services are required to establish a maintenance 
program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point cannot be 
provided at a lower level of care. Our physician reviewer found that the enrollee's condition meets Medicare 
criteria for SNF 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care for the enrollee.  
 
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: Favorable

We decided that the Plan has to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an SI injection is covered when specific criteria 
are met. 
 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the submitted records show that you have 
chronic low back and buttock pain. The physical exam is positive for sacroilitis. The Medicare rules do not 
require advanced imaging of the SI joint prior to the SI joint injection. The requested injection is reasonable 
and medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve a sacroiliac (SI) joint injection.  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the standing transfer aid provided on May 15, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the standing transfer aid. You say that you were not familiar with insurance 
policies regarding durable medical equipment. You needed the device in order to allow your care givers to 
transfer your safely. The Plan denied your request. The Plan says the plan cannot pay a provider who is not 
eligible to participate in Medicare. If you go to a provider who is not eligible to participate in Medicare. 
 
The plan must follow Medicare rules. Medicare rules say that the Plan will generally cover your medical care 
as long as the care you receive is considered medically necessary and you receive your care from a provider 
who is eligible to provide services under Original Medicare. 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 standing 
transfer aid provided on May 15, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 4, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on March 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultra-lightweight wheelchair and accessories.

You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says it is not clear why your needs could not be accommodated by a K0001-K0004 wheelchair.

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 wheelchair. Our reviewer says that the requested wheelchair is not considered medically reasonable and necessary in this case. Our physician reviewer found that the documentation does not reveal that your wheelchair cannot be accommodated by a K0001 through K0004 manual wheelchair. The documentation does not reveal that you had a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents
the medical necessity for the wheelchair and its special features and that the LCMP has no financial relationship with the supplier. 

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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultra-lightweight wheelchair and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 very heavy duty power operated vehicle. 
 
You asked the Plan to pre-approve a group 2 very heavy duty power operated vehicle. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for 
the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that a Very Heavy Duty Power Operated Vehicle 
(POV) is covered for a beneficiary weighing 428 - 600 pounds.  
 
We looked at the file and Medicare rules. Review of the file does not support that your weight is between 428 
and 600 pounds. Based on this information, we decided that Medicare rules for coverage of a group 2 very 
heavy duty power operated vehicle have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a group 2 very heavy duty power operated vehicle.