Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an arthroplasty (26535) and tissue transfer (14040) provided. 
 
You asked the Plan to pay for an arthroplasty and tissue transfer. You say that the records support these codes. 
The Plan denied your request. The Plan says these codes are not documented in the submitted records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for an arthroplasty and tissue transfer. Our 
reviewer says that these codes are not supported. Our physician reviewer found the operative note describe a 
joint capsule repair, not an arthroplasty.  The operative note describes a complex wound closure, not a tissue 
transfer. 
 
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 arthroplasty and tissue transfer have not been met. Therefore, we decided 
that the Plan does not have to pay for an arthroplasty (26535) and tissue transfer (14040) provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nutritional supplement drink/shake, Ensure  (B4150). 
 
You asked the Plan to pre-approve nutritional supplement. You say that Ensure is expensive and you cannot 
afford the nutrient you need for your bones. You feel that your insurance should cover any supplemental drink 
for your condition. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan 
does not have to pre-approve nutritional supplement drink/shake, Ensure  (B4150).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation. 
 
 
You asked the Plan to pre-approve the genicular nerve radiofrequency ablation. You say that you would like 
reconsideration because this service is medically necessary for treatment of the member's condition. The Plan 
denied your request. The Plan says there is a lack of literature with satisfactory comparisons to other standard 
treatments. 
 
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 genicular nerve radiofrequency 
ablation. 
 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this procedure is considered an experimental/investigational and is the 
subject of on-going clinical trials. 
 
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 genicular nerve radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Opdivo (J9299). 
 
You asked the Plan to pre-approve Opdivo. 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. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Opdivo. Our reviewer says that the 
medication is medically necessary. Our physician reviewer found there is evidence in triple negative PD L1 
metastatic breast cancer that Opdivo can be of benefit. Given the diagnosis, the window for therapy is small. 
The treatment is indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have been met. Therefore, we decided that the Plan has to pre-approve 
Opdivo (J9299).  
 
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 pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve the semi-electric hospital bed. You say that it is felt that this type of bed 
would be the most beneficial to allow the enrollee to be safe. The Plan denied your request. The Plan says there 
is no documentation of a condition for which a semi-electric bed is needed. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
2. Requires attachments which can only be attached to a hospital bed; AND 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 requested semi-electric hospital bed is not considered medically reasonable and 
necessary. Our physician reviewer found the documentation submitted indicates that the enrollee has diagnoses 
of benign neoplasm of cerebral meninges and recurrent falls/history of falling. The documentation submitted 
states that the enrollee has trouble getting into a regular bed as she is not able to use her right arm and does not 
have support. The documentation submitted does not indicate that the enrollee has physical or positional 
 
 
defects which require provision of a medical-grade hospital bed. The documentation submitted does not 
indicate that the enrollee has a condition requiring positioning of the body in ways not feasible in an ordinary 
bed. The documentation submitted does not indicate that the enrollee's condition requires special attachments 
that cannot be fixed and used on an ordinary bed. The documentation submitted does not indicate that the 
enrollee's condition requires frequent change in body position and/or that there may be an immediate need for a 
change in body position. The documentation submitted does not support that a semi-electric bed is medically 
necessary for the enrollee. 
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair and a raised toilet seat. 
 
You asked the Plan to pre-approve a shower chair and raised toilet seat. You say that the enrollee has just had 
surgery and needs this equipment while she recovers. The Plan denied your request. The Plan says these items 
are not considered durable medical equipment and are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs and raised toilet seats are not 
covered because they are not primarily medical in nature.  
 
While these items may be appropriate in this case, neither the Plan nor Medicare offers coverage of these. 
Therefore, we decided that the Plan does not have to pre-approve a shower chair and a raised toilet seat.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 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 enrollee does not require skilled nursing 
services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely 
and effectively provide medically necessary and reasonable treatment in a SNF after the last covered date. The 
enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and 
judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable 
treatment in a SNF after the last covered date. The enrollee does not require skilled nursing or skilled therapy 
services (or a combination of these services) on a "daily basis" in a SNF after the last covered date. As a 
practical matter, this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing 
 
 
facility setting after the last covered date. 
 
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 skilled nursing facility (SNF) care.
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. The Plan denied your request. The Plan says you do not need to be 
seen by a rehab physician 3 times a week, or an intensive team for care. 
 
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 physician reviewer found 
that you were admitted to the acute hospital for a knee replacement. Your medical problems are stable. The 
complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. While the record supports a need for physical and 
occupational therapy, there is no documented need for an intensive rehabilitation therapy program. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (CPT 99291) provided to the enrollee 
on November 11, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99291 (1 Unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is "critical care visit, 30-74 minutes." 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found CPT 
99291 is a time based code. In order to bill CPT 99291 the amount of time spent providing critical care services 
to the enrollee must be documented.  The provided documentation does not note how much time was spent 
providing services to the enrollee.  Therefore, the billing of CPT 99291 is not supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for critical care services (CPT 99291) provided to the enrollee on November 11, 2019.
Appeal type: Practitioner Services
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 on March 19, 2020, and March 20, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says prior authorization was 
not obtained. 
 
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 
on March 19, 2020, and March 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental surgery procedure and anesthesia for intraoral 
procedures. 
 
You asked the Plan to pre-approve the dental surgery procedure and anesthesia. You say that you are waiting 
for two shoulder surgeries, but cannot proceed with the shoulder surgeries due to having a constant infection in 
your mouth. The Plan denied your request. The Plan says the dental surgery procedure and anesthesia are not 
covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a dental surgery 
procedure and anesthesia for intraoral procedures.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have problems walking. The Plan denied 
your request. The Plan says the items are not covered in your case. 
 
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 foot orthotics.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on March 17, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
services provided on March 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an emergency alert communication system. 
 
You asked the Plan to pre-approve an emergency alert communication system. You say that this is important 
for your safety because you live alone. The Plan denied your request. The Plan says that this item is not 
covered. 
 
The Plan must follow Medicare rules. The rules say that telephone alert systems are excluded from coverage as 
these are emergency communications systems and do not serve a diagnostic or therapeutic purpose. 
 
Although this device may be appropriate, it is not covered by Medicare. Therefore, we decided that the Plan 
does not have to pre-approve an emergency alert communication system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 17, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed without the appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that if the same physician or other supplier entity 
does not furnish both the TC and PC of the diagnostic service, or if the same physician or other supplier entity 
furnishes both the TC and PC but the professional interpretation was furnished in a different payment locality 
from where the TC was furnished, the professional interpretation of a diagnostic test must be separately billed 
with modifier -26 by the interpreting physician. 
 
We looked at the file and Medicare rules. The codes in question are required to be billed with modifier -26, but 
have not been in this case. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on January 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
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 the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM 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 
you do not meet the criteria for coverage. Our physician reviewer found the submitted records show that you 
have Type 2 diabetes with high blood sugar and long-term use of insulin. It is documented that you use Lantus 
insulin once daily at night and are not testing your blood sugar more than once per day. You are not insulin-
treated with three or more daily injections and are not performing glucose testing four or more times a day; 
therefore, the CGM is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-
network provider. 
 
You asked the Plan to pre-approve the physician's services. You say that you would like a follow up visit with 
this physician to discuss the results of the MRI scan. The Plan denied your request. The Plan says referrals will 
first be made to an in-network provider as long as the specialist is able to provide the same service to the 
patient. Based on the notes received from your doctor, the exam can be done with an in-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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a leg pillow. 
 
You asked the Plan to pre-approve a leg pillow. The Plan denied your request. The Plan says the requested item 
is considered non-medical in nature. 
 
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 a leg pillow.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve epidural injection. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-
network with the Plan and this service can be provided by an in-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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an out-of-network (OON) provider.