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

 
We decided that the Plan has to pre-approve a CT scan. 
 
You asked the Plan to pre-approve a CT scan. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says that the requested CT scan is not medically necessary. 
 
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 a CT scan. Our reviewer says that the 
documentation does support that the requested CT scan is medically reasonable and necessary. The 
documentation indicates that per the radiology recommendation a follow-up CT scan was recommended to 
evaluate fibrocalcific opacities in the left lung apex suspicious for postinflammatory changes from previous 
granulomatous disease. A central stellate focus is present which is also likely postinflammatory. The CT scan is 
required regardless of physical exam/CXR findings. Therefore, the enrollee meets criteria for the requested CT 
scan. Our physician reviewer found the enrollee was diagnosed with imaging of an abnormal lung. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a CT scan.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 5, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says screening tests are not covered. 
 
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 test 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 rendered on June 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services provided by an out of 
network provider. 
 
You asked the Plan to pay for the vision services. You say that you did not know the doctor was out of 
network. The Plan denied your request. The Plan says you did not request prior authorization for the out of 
network 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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 vision services 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 shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says a shower chair is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor. 
 
You asked the Plan to pre-approve continuous glucose monitor. You say that you are appealing at the enrollee's 
request. The Plan denied your request. The Plan says the denial of authorization for this continuous glucose 
monitor is correct, because the enrollee does not test blood glucose 4 or more times per day. 
 
The Plan follows Medicare rules. Medicare rules say that a continuous glucose monitor is only covered if all 6 
of the above listed criteria have been 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 continuous glucose monitor. Our 
reviewer says that the enrollee does not meet the Medicare criteria for the requested continuous glucose 
monitor. Our physician reviewer found the enrollee has not been asked to test blood glucose 4 or more times 
 
 
per day. He only takes Lantus insulin once daily. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuous glucose monitor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Dexcom continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea FreeStyle Libre continuous glucose monitor (CGM) (K0553, K0554).You asked the Plan to pre-approvea FreeStyle Libre CGM. You say that this is medically necessary.The Plan denied your request. The Plan says you do not meet the criteria for coverage.The Plan must follow Medicare rules. Medicare rules say that CGMs and related supplies are covered by Medicare when the beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump.We looked at the file and Medicare rules. The records do not show that you are insulin-treated with three or more daily injections of insulin. Based on this information, we decided that Medicare rules for coverage of a FreeStyle Libre CGM have not been met.Therefore, we decided that the Plan does not have to pre-approvea FreeStyle Libre continuous glucose monitor (CGM) (K0553, K0554).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).You asked the Planto pre-approvethe SNF admission. You say that the enrollee would benefit from SNF care to help regain her independence.The Plandenied your request. The Plansaysthe enrollee doesnot require daily skilled services to improve or maintain her condition.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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female who was admitted to acute inpatient rehabilitation on 9/30/2020 after a stroke causing left-sided hemiplegia. As of 10/19/2020, her mobility status remains at maximal assist to standup and sit down and she is non-ambulatory. The enrollee does not have documented skilled nursing needs.The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition.The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of 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 the SNF admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 13, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says screening tests are not covered. 
 
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 test at issue in this appeal, a cardiovascular risk assessment panel, 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 rendered on May 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower/bath chair. 
 
You asked the Plan to pre-approve a shower/bath chair. You say that a shower/bath chair is medically 
necessary. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower/bath chair.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for wheelchair van transport for the enrollee. 
 
You asked the Plan to provide coverage for this transport. You say that this transport is necessary for the 
enrollee. The Plan denied your request. The Plan says this type of transport is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to provide coverage for are wheelchair van transport services. Therefore, 
we decided that the Plan does not have to provide coverage for wheelchair van transport for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve therapeutic radiology treatment planning; complex (CPT Code 
77263), Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, 
off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as 
required during course of treatment, only when prescribed by the treating physician  (CPT Code 77300) and 
intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial 
tolerance specifications (CPT Code 77301). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says that there is no current research showing that this enrollee's type of cancer responds 
better to the requested type of treatment than the type of treatment the Plan can approve. 
 
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 services. Our physician reviewer 
found the LCD allows IMRT for metastatic primary or benign tumors of the brain and the services should be 
approved on that 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 services have been met. Therefore, we decided that the Plan has to pre-
approve therapeutic radiology treatment planning; complex (CPT Code 77263), Basic radiation dosimetry 
calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue 
inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course 
of treatment, only when prescribed by the treating physician  (CPT Code 77300) and intensity modulated 
radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance 
specifications (CPT Code 77301).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair repairs. 
 
You asked the Plan to pre-approve wheelchair repairs. You say that you have had your chair repaired several 
times. The Plan denied your request. The Plan says an institution may not be considered a home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
The records show that wheelchair repairs are being requested for use in a SNF. Medicare does not consider a 
SNF or a hospital to be a home. Therefore, we decided that the Plan does not have to pre-approve wheelchair 
repairs.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve radiopharmaceutical localization of tumor, inflammatory process 
or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when 
performed); tomographic (SPECT), single area (eg, head, neck, chest, pelvis), single day imaging (CPT Code 
78803 and radiopharmaceutical localization of tumor, inflammatory process or distribution of 
radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); planar, whole 
body, requiring 2 or more days imaging (CPT Code 78804). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says that the services are not 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 the services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the patient has a condition which causes tumors, and surveillance is warranted via SPECT, so 
yes, they have an approved indication. Due to the patient's prior tumor history and propensity to develop new 
tumors, SPECT (78803,78804) is reasonable and medically necessary for this patient's condition. 
 
 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve radiopharmaceutical localization of tumor, inflammatory process or distribution of 
radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic 
(SPECT), single area (eg, head, neck, chest, pelvis), single day imaging (CPT Code 78803 and 
radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical 
agent(s) (includes vascular flow and blood pool imaging, when performed); planar, whole body, requiring 2 or 
more days imaging (CPT Code 78804).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entresto. 
 
You asked the Plan to pre-approve Entresto. The Plan denied your request. The Plan says the medication does 
not fall under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Entresto.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve elective inpatient hospital admission from October 27, 
2020, to October 29, 2020, for procedure: radioactiveiodine. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found most people receiving radioactive iodine stay one (1) night in hospital. The services 
are not 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve elective inpatient hospital admission from October 27, 2020, to October 29, 
2020, for procedure: radioactiveiodine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infection control supplies. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code S8301 is not payable. 
 
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid 
for Medicare purposes. 
 
We looked at the file and Medicare rules. The provider submitted a claim for procedure code S8301. This code 
has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not 
have to pay for the infection control supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation rendered on June 6, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the 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 service at issue is not manual manipulation of the spine. The file shows that the 
provider submitted a claim for procedure code G0283 (electrical stimulation). Therefore, we decided that the 
Plan does not have to pay for the electrical stimulation rendered on June 6, 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 (99213) 
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 (99213) provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that the requested continuation of 
SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for continued SNF 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 the continuation of SNF care. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the 
documentation provided, the enrollee does not have documented skilled nursing needs.  The enrollee does not 
have documented skilled therapy needs.  The enrollee appears to have reached a plateau in function.  Daily 
skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's 
condition.  The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a 
lower level of 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 the continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve exercise equipment. 
 
You asked the Plan to pre-approve the equipment. You say that gyms and many other facilities are closed due 
to COVID-19. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve exercise equipment.