Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's rehab 
and skilled care needs are not complex. 
 
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 the enrollee was admitted to the acute hospital for peripheral vascular disease and cellulitis of right leg, 
congestive heart failure and malignant pericardial effusion. Her medical conditions are stable. The complexity 
of her nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (CPT 71045) provided to the enrollee on June 
29, 2020. 
 
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 the submitted documentation supports only one unit of 71045-26, which was previously 
approved/paid. 
 
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 71045 is "radiologic examination, chest; single view." 
 
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 a review 
of the submitted records demonstrates a single AP chest film was done on the date of service; 6/29/20. 
Accession code was 122463421 and the exam was signed and verified by the doctor on 6/29/20 at 3:13. No 
additional report indicating a second exam was done is enclosed. 
 
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 a chest x-ray (CPT 71045) provided to the enrollee on June 29, 2020.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the emergency care provided on June 24, 2020. 
 
You asked the Plan to pay for the emergency care. The Plan denied your request. The Plan says that this service 
is not allowed when performed at this place of treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The emergency services in question were billed with POS 23 (Emergency Room 
- Hospital). This is an appropriate place of service for the billed code. The Plan has not submitted supporting 
documentation to substantiate its denial. Therefore, we decided that the Plan has to pay for the emergency care 
provided on June 24, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on March 16, 2020, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 physician services provided on March 16, 
2020, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) for the 
lower right quadrant. 
 
You asked the Plan to pre-approve the dental service. You say that you have diabetes. You say that you need 
this service because your gums will not heal. The Plan denied your request. The Plan says periodontal scaling 
and root planing is not listed as a covered service. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
periodontal scaling and root planing (D4341) for the lower right quadrant.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional accessories for a wheelchair (E2377, E2313, 
E2311, K0108) for the enrollee. 
 
You asked the Plan to pre-approve the accessories. 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 accessories. Our reviewer says that 
the requested accessories are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not reveal that the enrollee needs an expandable controller to operate 
other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, 
head control, etc.), non-proportional input devices (e.g., sip and puff, head array, etc.), or to operate 3 or more 
powered seating actuators through the drive control. The documentation does not reveal the enrollee needs the 
expandable controller to operate a separate display (i.e., for alternate control devices), other electronic devices 
(e.g., control of an augmentative speech device or computer through the chair's drive control), or for an 
attendant control. The enrollee has sufficient strength in the upper extremities and functional ability to operate 
any power options through their own individual switches. The backshell kit, back cushion, backrest wedge, and 
back wedge exceed the enrollee's need. The enrollee was already approved for a wheelchair cushion and 
headrest and the documentation does not support the necessity of the separate K0108 backshell kit, K0108 back 
cushion, K0108 backrest wedge and K0108 back wedge with separate K0108 coding. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional accessories for a wheelchair (E2377, E2313, E2311, K0108) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the colonoscopy provided on September 
24, 2020. 
 
You asked the Plan to waive the coinsurance for the colonoscopy. You say that you should not be responsible 
for the copayment because the doctor did not complete the colonoscopy. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing amount. 
 
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 25% of 
the cost at an in-network outpatient hospital.  
 
You have been asked to pay $190.91 which is 25% of the allowed amount for the colonoscopy. The allowed 
amount is $763.65. ($763.65 x 25% = $190.91). The colonoscopy falls within the Outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. 
The medical record shows that the cecum was not fully visualized. However, the diagnostic colonoscopy 
procedure was performed. 
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for the colonoscopy provided on September 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve exploration of spinal fusion (22830), laminectomy, 
facetectomy and foraminotomy (63047), arthrodesis, posterior or posterolateral technique (22612), posterior 
non-segmental instumentation (22840) and allograft for spine surgery (20931) and diagnostic bone marrow 
(38220) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the request was appropriately denied. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Bone marrow 
aspirate remains experimental. More research is needed to show safety and efficacy. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for coverage. 
 
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 exploration of spinal fusion (22830), laminectomy, facetectomy and foraminotomy 
(63047), arthrodesis, posterior or posterolateral technique (22612), posterior non-segmental instumentation 
(22840) and allograft for spine surgery (20931) and diagnostic bone marrow (38220) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
with humidifier and supplies. 
 
You asked the Plan to pre-approve CPAP device. You say that you are waiting for approval of a sleep study 
and if you do not have this device it could cause health issues. The Plan denied your request. The Plan says the 
denial of authorization for this oxygen equipment is correct, because this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that a CPAP device is only covered when all of the 
above listed 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 CPAP device. Our reviewer says that 
you do not meet the Medicare criteria for the requested CPAP. Our physician reviewer found a clinical note 
indicates that you are not using your CPAP, and that you are intolerant of CPAP. There is no compliance data 
from the device. It would be reasonable to proceed with the scheduled follow-up visit and sleep study. CPAP 
can then be reinstituted on a trial basis pending a compliance assessment. 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPAP device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous positive airway pressure (CPAP) device with humidifier and supplies.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcatheter insertion of a permanent leadless 
pacemaker (33274). 
 
You asked the Plan to pre-approve transcatheter insertion of a permanent leadless pacemaker. You say that the 
services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria has not been met. 
 
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 transcatheter insertion of a permanent 
leadless pacemaker. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found in this circumstance if a pacemaker is 
thought to be medically necessary then a leaded system if preferred to maintain AV synchrony. There is no 
documented contraindication to a leaded system such as lack of venous access. In addition, leadless 
pacemakers remain somewhat investigational especially with respect to long term follow up. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transcatheter insertion of a permanent leadless pacemaker have not been met. 
Therefore, we decided that the Plan does not have to pre-approve transcatheter insertion of a permanent 
leadless pacemaker (33274).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would benefit from IRF. The Plan denied your 
request. The Plan says the denial of authorization for IRF admission is correct. 
 
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. Your conditions are 
stable. There are no medical needs requiring inpatient admission. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided to the enrollee from April 
14, 2020, to May 15, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
service when provided by a chiropractor. 
 
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 services provided to the enrollee from April 14, 2020, to 
May 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan (78815). 
 
You asked the Plan to pre-approve the PET scan. You say that the service is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 the PET scan. Our reviewer says that 
the PET scan is not medically necessary. Our physician reviewer found the PET scan is approved to detect 
recurrence in men with elevated PSA following prior treatment. In this case, the enrollee is newly diagnosed 
and there is not recurrent disease. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Positron Emission Tomography (PET) scan (78815).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Uloric. 
 
You asked the Plan to pre-approve Uloric. You say that the enrollee's liver specialist does not want the enrollee 
to take Allopurinol. The Plan denied your request. The Plan says this is a self-administered drug. The Plan also 
says that this drug is not covered for the enrollee's condition by Medicare 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 Uloric.  
 
Benefits for Uloric may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture. 
 
You asked the Plan to pre-approve these services. You say that the denture you have is painful to wear. The 
Plan denied your request. The Plan says the request exceeds the benefit limit. 
 
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. The Plan covers one upper 
partial denture every five plan years.  
 
We looked at the file and Medicare rules. The file shows that you received an upper partial denture on July 18, 
2017 for which the Plan approved and paid. You are not eligible for a new upper partial denture until five years 
have passed from this date. Therefore, we decided that the Plan does not have to pre-approve an upper partial 
denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the all-white glass crown (D2740). 
 
You asked the Plan to pre-approve the all-white glass crown. You say that this service is medically necessary 
for the enrollee. The Plan denied your request. The Plan says this service is not medically necessary. 
 
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. The Plan covers the all-white 
glass crown when the services are medically necessary and reasonable.  
 
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 all-white glass crown. Our reviewer 
says that the service requested is not medically necessary. Our physician reviewer found the provided X-ray is 
not sufficiently diagnostic as to allow for a determination of the quality of the root canal filling. Given the lack 
of a diagnostic radiograph, the Plan criteria has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the all-white glass crown have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the all-white glass crown (D2740).