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

 
We decided that the Plan does not have to pre-approve an Echocardiography, transthoracic. 
 
You asked the Plan to pre-approve an Echocardiography, transthoracic, real-time with image documentation 
(2D), includes M-mode recording, when performed, complete, without spectral or color Doppler 
echocardiography (93307). You say that the enrollee needs a transthoracic echocardiogram. The Plan denied 
your request. The Plan says Echocardiography, transthoracic is not medically necessary as the clinical record 
does not document a heart muscle problem. 
 
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 Echocardiography, transthoracic, real-
time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral 
or color Doppler echocardiography (93307). Our reviewer says that the service is not medically necessary. Our 
physician reviewer found coverage criteria for a transthoracic echocardiogram (TTE) are not met. This enrollee 
has a diagnosis of chronic obstructive pulmonary disease (COPD), and is short of breath. The pulmonologist's 
note of July 13,2020 does not describe any evidence of cardiac dysfunction on physical examination. The plan, 
indicated in the note, is to get chest imaging and pulmonary function tests; the plan did not include TTE and the 
note did not provide justification for this test. TTE is considered not medically necessary, and the denial is 
upheld. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Echocardiography, transthoracic, real-time with image documentation (2D), 
includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography 
(93307) have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
Echocardiography, transthoracic.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair and accessories. 
 
You asked the Plan to pre-approve a group 2 power wheelchair and accessories. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 group 2 power wheelchair and 
accessories. Our reviewer says that the documentation does not support that the requested power wheelchair is 
medically reasonable or necessary. Our physician reviewer found the documentation does support that the 
enrollee has a mobility deficit but the documentation is not consistent and does not support that this deficit 
significantly interferes with her ability to perform mobility related activities of daily living in the home. The 
documentation does not support indicate that the enrollee's mobility deficit cannot be alleviated with a properly 
configured manual wheelchair or walker as there is no gait evaluation, no objective evidence of current 
deQuervain's tenosvnovitis on a physical exam, no detailed physician evaluation of the upper extremities. The 
May 27, 2020 physician office note does not support that the enrollee has shortness of breath on household 
distances. Therefore, the enrollee does not meet criteria for the requested power wheelchair and accessories. 
 
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 group 2 power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 2 power wheelchair and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee needs a CGM. The 
Plan denied your request. The Plan says the enrollee is not insulin treated and therefore does not meet the 
Medicare coverage criteria for a CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The enrollee is not insulin treated therefore the Medicare coverage 
criteria for a CGM is not met. Based on this information, we decided that Medicare rules for coverage of a 
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (EKG) interpretation and report 
rendered on November 13, 2019. 
 
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 93010 is 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 93010 is electrocardiogram, routine ECG with at least 12 
leads; interpretation and report only. 
 
We find that CPT code 93010 is not supported in the medical record. Specifically, there is no documentation of 
interpretation and report of EKG for the date of service at issue. 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 pay for the electrocardiogram (EKG) interpretation and report rendered on November 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 standard power operated vehicle. 
 
You asked the Plan to pre-approve a scooter. You say that you need a scooter because you can't walk around 
the house and do basic functions. The Plan denied your request. The Plan says there is no indication you have 
met any of the guidelines for a power mobility device. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file does not show that you have a mobility deficit that impairs your participation in MRADLs, your 
condition cannot be improved by a walker, cane or manual wheelchair, or that you can safely operate the PMD 
being requested. There is no physician order, face-to-face documentation or home assessment documentation. 
This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Group 1 standard power operated vehicle.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Magnetic Resonance Imaging (MRI) of the foot. 
 
You asked the Plan to pre-approve a Magnetic resonance (eg, proton) imaging, lower extremity other than 
joint; without contrast material(s) (77318). You say that the enrollee needs an MRI to assess the area. The Plan 
denied your request. The Plan says an MRI for heel pain in left foot is not medically necessary. 
 
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 a Magnetic resonance (eg, proton) 
imaging, lower extremity other than joint; without contrast material(s) (77318). Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has chronic bilateral knee pain 
due to osteoarthritis. The enrollee complained of left heel pain which started after a right inguinal hernia 
surgery. Steroid injections to the heel, NSAIDs, stretching, and shoe inserts were not helpful. The left heel was 
tender to palpation. MRI left foot was requested. No evidence of having had a foot x-ray was provided. 
Although conservative treatment was attempted providing minimal benefit, the physical findings and history 
suggest a bony abnormality. X-ray would be indicated and was not evidenced as having been completed. There 
was no other indication noted to help justify an MRI at this time. Therefore, this request for MRI left foot will 
be considered not 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 a Magnetic resonance (eg, proton) imaging, lower extremity other than joint; 
without contrast material(s) (77318) have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Magnetic Resonance Imaging (MRI) of the foot.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a wireless pulmonary artery pressure 
sensor (CardioMEMS). 
 
You asked the Plan to pre-approve CardioMEMS. You say that a trial showed significant improvements for 
patients monitored by the CardioMEMS system. The Plan denied your request. The Plan says the denial of 
authorization for this procedure is correct, because CardioMEMS is experimental/investigational. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found therapy change based on data obtained from a CardioMEMS device has been demonstrated in 
only 1 trial to help reduce hospital readmission compared to standard medical therapy. Furthermore, concerns 
have been raised about potential bias in this trial calling into question its results. The efficacy of the 
CardioMEMS device is uncertain at this time and not recommended in current guidelines for the treatment of 
heart failure. This device should still be considered experimental/investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve implantation of a wireless pulmonary artery pressure sensor (CardioMEMS).
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 are in dire need of inpatient rehabilitation. The 
Plan denied your request. The Plan says the denial of authorization for IRF service 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 medical problems 
are stable with no complex nursing or rehabilitation needs. The medical records do support a need for physical 
therapy and occupational therapy, but do not support a need for or ability to tolerate 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 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a Computed Tomography (CT) scan of the cervical spine. 
 
You asked the Plan to pre-approve CT scan. You say that the enrollee has had prior cervical surgery, is in 
severe pain, and has done physical therapy with no relief. The Plan denied your request. The Plan says that the 
denial of authorization for this CT scan is correct. 
 
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 CT scan. Our reviewer says that the 
enrollee meets the Medicare criteria for the requested CT scan. Our physician reviewer found the enrollee has 
documented prior cervical spine surgery, failed physical therapy, and radicular pain in nature. CT scan is 
medically reasonable and 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 CT scan have been met. Therefore, we decided that the Plan has to pre-approve 
a Computed Tomography (CT) scan of the cervical spine.  
 
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 incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that these are necessary for multiple medical 
conditions. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upper and lower partial denture. 
 
You asked the Plan to pre-approve the upper and lower partial denture. You say that you cannot eat without 
dentures. You say that your current set is damaged and you cannot use them. The Plan denied your request. The 
Plan says the denture benefit is exhausted. 
 
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, you also have a maximum benefit of 
one partial or full denture every 5 years. You received dentures on August 30, 2016, which exhausted your 
benefit. Therefore, we decided that the Plan does not have to pre-approve the upper and lower partial denture.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve CT scan of the lower extremity for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is insufficient clinical information to approve the requested study. 
 
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 the scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found while plain x-rays are 
useful to evaluate gouty arthritis of the first toe, CT is a much better test to evaluate erosive changes of multiple 
digits. The enrollee has had arthroplasty on the right and progressive changes on plain x-rays. CT is appropriate 
for more advanced evaluation and should be approved. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
CT scan of the lower extremity for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the abdomen for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says an ultrasound may help to confirm the diagnosis, or may help determine the next 
appropriate imaging test. 
 
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 the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found no medical records 
have been submitted. The nature of the chronic liver disease is not presented. Prior imaging tests are unknown. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the abdomen for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that the enrollee is not a good candidate for alternative 
drugs. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because 
this drug is not covered by Medicare Part B under the circumstances. 
 
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 Ilumya.  
 
Benefits for Ilumya 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist services. You say that you would like approval for these visits. 
The Plan denied your request. The Plan says there are multiple in-network providers available for these 
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 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 
specialist services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says 30 days of 
coverage to start dialysis at the in-network facility. 
 
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. The file shows that the Plan has agreed to 
approve 30 days of services from an out-of-network provider. We found no exception that would require the 
Plan to pre-approve additional OON services at this time. Therefore, we decided that the Plan does not have to 
pre-approve additional dialysis services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says in-network 
providers are available to provide the service. 
 
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 at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve durable 
medical equipment to be provided by an out of network (OON) provider.