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

 
We decided that the Plan does not have to pre-approve the office visit (99245) to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that the out-of-network provider should be covered. 
The Plan denied your request. The Plan says the requested services are not emergent or pre-authorized. There 
are network providers available. 
 
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 the office 
visit (99245) 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 a Group 1 power operated vehicle. 
 
You asked the Plan to pre-approve a power operated vehicle (scooter). You say that you do not like the power 
wheelchair. The Plan denied your request. The Plan says you have a power wheelchair and repairs can be made 
to move the joystick control. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a power wheelchair. Your power wheelchair serves the same purpose as a power 
operated vehicle (scooter). This power wheelchair is still within the 5-year RUL and the documentation 
submitted does not show that your power wheelchair is irreparably worn, irreparably damaged, or that you have 
had a change in medical condition to warrant the scooter at issue. Based on the records provided, there is no 
indication that a replacement power mobility device meets Medicare coverage criteria. Therefore, we decided 
that the Plan does not have to pre-approve a Group 1 power operated vehicle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the claim should be paid. The 
Plan denied your request. The Plan says PCDs billed by E0675 are not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. PCDs billed by E0675 are not 
covered. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0675).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator. 
 
You asked the Plan to pre-approve the requested oxygen. The Plan denied your request. The Plan says coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or 
arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.   
 
We looked at the file, and Medicare rules. The documentation in the case file show that the enrollee's oxygen 
level was at or above 96%. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you need a new scooter. The Plan denied your 
request. The Plan says that there were no documented clear exam findings to validate the statements made 
regarding your strength and medical need. 
 
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 a power scooter. Our reviewer says that 
a power scooter is not considered medically reasonable and necessary in this case. The documentation does 
reveal that you have a personal mobility deficit that impairs participation in MRADLs in the home. You are 
noted to be unable to use a manual wheelchair or walker due to upper extremity and lower extremity weakness, 
however, the neuromuscular exam is not detailed in regards to strength and function of individual muscle 
groups or mytomes. The documentation reveals you have the cognition and vision to safely operate a power 
mobility device but there is no in person assessment of your apartment to evaluate whether you can safely 
maneuver the power mobility device in the home. Our physician reviewer found that your condition does not 
meet Medicare criteria for a power scooter. 
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower partial denture (D5214). 
 
You asked the Plan to pre-approve the dental item. You say that you have had several bottom teeth pulled after 
getting your bottom denture. You say that now the bottom denture does not fit properly. You say that you are 
not able to eat and are experiencing discomfort. You also say that you cannot fit the bottom denture. The Plan 
denied your request. The Plan says dentures are covered once every 5 plan years. The Plan also says that the 
frequency limit for a lower partial denture has been reached. 
 
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 and dentures are a covered service, the 
frequency limit of once every 5 plan years has been reached. The record shows that you received a lower partial 
denture on February 27, 2018. Therefore, we decided that the Plan does not have to pre-approve a lower partial 
denture (D5214).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a lower level of care is inappropriate. 
The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that LTACHs are certified as acute care hospitals, and in general, LTACHs do not 
provide clinical services that are materially different than those of short term acute care hospitals. The enrollee 
is receiving acute hospital care and acute care services have not been denied. The documentation does not 
support that the enrollee in this case requires services at the LTACH that are not available at the acute care 
hospital where the enrollee is currently receiving care. Consequently, the requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox. 
 
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. The rules say that Botox is covered when specific criteria are met.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
gastroparesis. She had an upper endoscopy with Botox injection at the pylorus on August 10, 2020 and 
experienced one week without any reflux symptoms. The symptoms came back, but at first they were better 
than they previously were; however, the enrollee's symptoms have gotten progressively worse. The enrollee 
does not have a condition for which Medicare covers Botox injections. The services are therefore 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 Botox.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 28, 
2020 to April 27, 2020. 
 
You asked the Plan to pay for SNF care. You say that this should be covered by Medicare. The Plan denied 
your request. The Plan says the skilled nursing care provided was not medically necessary. 
 
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 pay for SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found daily skilled services were not required to 
establish a maintenance program or to prevent deterioration of the enrollee'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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from March 28, 2020 to April 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wig. 
 
You asked the Plan to pre-approve a wig (A9282). You say that the enrollee needs a wig due to hair loss from a 
medical condition. The Plan denied your request. The Plan says a wig does not serve a medical purpose and 
therefore cannot be approved. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a compression sleeve identified with code A6549. 
 
You asked the Plan to pre-approve a compression sleeve. You say that an arm compression sleeve is the 
appropriate treatment for the enrollee. The Plan denied your request. The Plan says a compression sleeve is not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a compression 
sleeve identified with code A6549.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alveoloplasty services and the removal of torus 
mandibularis. 
 
You asked the Plan to pre-approve the dental services. You say that you cannot afford to get an infection. The 
Plan denied your request. The Plan says the services are not a covered benefit. 
 
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. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
alveoloplasty services and the removal of torus mandibularis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve excision of osseous tuberosities and maxillary mandible 
bone grafts for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is needed due to periodontal gum disease. The 
Plan denied your request. The Plan says this is not a covered benefit. 
 
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 the enrollee's teeth or the structures directly supporting the enrollee's 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 
excision of osseous tuberosities and maxillary mandible bone grafts for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Praluent. 
 
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 self-administered drugs are not covered. 
 
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 Praluent.  
 
Benefits for these services 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve minimally invasive lumbar decompression (MILD). 
 
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 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 services are not medically necessary. Our physician reviewer found the enrollee has low back pain. The 
MILD procedure is experimental in nature, as more research is needed to show safety and efficacy. It is not the 
standard of care and 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 minimally invasive lumbar decompression (MILD).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tramadol HCL tab 50mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this medication is not covered. 
 
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 Tramadol HCL tab 50mg 
for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) can of the abdomen and pelvis 
(74178). 
 
You asked the Plan to pre-approve a CT scan. You say that this is medically necessary to screen for 
hepatocellular carcinoma. The Plan denied your request. The Plan says that there is not clinical documentation 
to support this. 
 
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 
requested CT scan is medically necessary. Our physician reviewer found the enrollee's body mass index (BMI) 
merits exception to every-6 month ultrasound screening. Further, in her case, fatty liver with marked 
parenchymal heterogeneity is likely. This scenario qualifies as medically necessary for the CT scan as 
requested. 
 
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 computed tomography (CT) can of the abdomen and pelvis (74178).  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for an inpatient hospital stay for the enrollee. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the services could have been delivered in a short-stay (observation) 
level of care. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
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 been met. Therefore, we decided that the Plan 
has to pay for an inpatient hospital stay for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you will be more likely to heal properly and regain 
as much movement as possible with inpatient rehabilitation. The Plan denied your request. The Plan says rules 
for IRF care have not been met. 
 
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. There are no identified 
problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. You 
do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational 
therapy but it does not support a need for 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 IRF admission and services.