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

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy for the enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence of a three month trial of conservative therapy. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the coverage criteria requires that the enrollee's lifestyle-limiting symptoms be attributable to the 
varicose veins. In this case, the saphenous reflux does not explain the enrollee's buttock cramping while trying 
to walk or climb stairs. As the enrollee has both hypertension and hypercholerosteremia, she is at risk for 
peripheral artery disease particularly with symptoms that are consistent with claudication. It is unclear how 
greater saphenous vein ablation will resolve thigh and buttock cramping with activity. Additionally, there is no 
documentation in the medical record of concerted efforts at conservative therapy. The documentation about 
previous use of stockings is not sufficient for this unless accompanied by a previous office visit at which the 
time the prescription for the stockings was provided. 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endovenous ablation therapy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Roho Smart Check (K0108) and a power seat 
elevation system (E2300) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says these items do not serve a primarily medical purpose. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the power seat elevation system is not covered as it is not primarily medical in nature. The K0108 (one 
unit) for Roho Smart Check is a convenience item used to check cushion inflation and does not serve a medical 
purpose. There is no specific medical necessity for this item. 
 
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 pre-approve a Roho Smart Check (K0108) and a power seat elevation system (E2300) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by THE Fire 
and Rescue on August 17, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 17, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by THE Fire and Rescue on August 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you're not able to transfer from your 
wheelchair and have fallen twice. 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 raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate for F. Stickle, neither the Plan nor Medicare offers coverage of 
this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
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 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 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 based on the medical records provided the complexity of the enrollee's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services 
but does not require an intensive inpatient rehabilitation therapy program. There is concern that the enrollee 
will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in 
an inpatient rehabilitation facility due to his cognitive decline and extreme lethargy. Care at the skilled nursing 
facility level appears to be more appropriate in this case. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reline of a complete maxillary denture provided on 
August 17, 2020 by an OON provider. 
 
You asked the Plan to pay for the reline of a complete maxillary denture. You say that you would like to appeal 
this claim. The Plan denied your request. The Plan says this service was rendered by an OON provider. The 
Plan also says that you do not have OON benefits that allows coverage with an OON provider without a prior 
authorization. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the reline 
of a complete maxillary denture provided on August 17, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation trips. 
 
You asked the Plan to pre-approve additional mileage for routine transportation trips. You say that the 
additional mileage is needed. The Plan denied your request. The Plan says the requested additional mileage 
exceeds the benefit limit. Therefore, coverage criteria has not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers unlimited one-way transportation trips per calendar year when each one-way trip does 
not exceed fifty miles per year. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan?s rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage for routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings. 
 
You asked the Plan to pre-approve the compression stockings. You say that the items 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. Medicare rules say that compression stockings are covered only when 
they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and 
gradient compression wraps are covered only when they are used as dressings over a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve palonosetron (J2469). 
 
You asked the Plan to pre-approve palonosetron. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not indicated for the enrollee. 
 
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 palonosetron. Our reviewer says that 
the requested palonosetron is not medically necessary at this time. Our physician reviewer found Gemzar is low 
emetogenic and the enrollee has not failed Zofran or Kytril. This use of palonosetron is not supported by the 
compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of palonosetron have not been met. Therefore, we decided that the Plan does not 
have to pre-approve palonosetron (J2469).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve retainer crowns (D6750) for tooth #'s 6, 7, 12, and 14 and pontics 
(D6242) for tooth #'s 8, 9, 10, and 11. 
 
You asked the Plan to pre-approve the retainer crowns and pontics. You say that the enrollee needs a new 
bridge to replace the old one. The Plan denied your request. The Plan says that a fixed bridge is not covered to 
bridge a large gap in the enrollee's native teeth. The Plan also says that a partial denture is covered, which 
should serve the same purpose. 
 
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 retainer 
crowns and pontics 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 retainer crowns and pontics. Our 
reviewer says that these services meet the criteria of medically reasonable and necessary. Our physician 
reviewer found an old fixed bridge had to be removed due to the recurrent caries and extraction of abutment 
#11. Tooth #'s 6, 7, and 12 which were abutment retainers for the old bridge need new crowns. Our reviewer 
also found that a new fixed bridge using #6, 7, 12, and 14 as abutment retainers is medically reasonable and 
necessary. 
 
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 retainer crowns and pontics have been met. Therefore, we decided that the 
Plan has to pre-approve retainer crowns (D6750) for tooth #'s 6, 7, 12, and 14 and pontics (D6242) for tooth #'s 
8, 9, 10, and 11.  
 
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 pneumatic compression garments (E1399). 
 
You asked the Plan to pre-approve the pneumatic compression garments. You say that the garments are 
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 a four-week trial of conservative therapy 
demonstrating failed response to treatment is required for a Pneumatic Compression device to be covered. 
 
We looked at the file and Medicare rules. No records of a four-week trial of conservative therapy were 
provided. The plan made requests for additional records and none were provided. Based on this information, 
we decided that Medicare rules for coverage of the pneumatic compression garments have not been met. 
Therefore, we decided that the Plan does not have to pre-approve pneumatic compression garments (E1399).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for the skin tag removal (11200) provided on September 29, 2020. 
 
You asked the Plan to hold you harmless for this service. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says that this service was cosmetic in 
nature and not payable under your contractual policy or by Medicare. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for this service by a contract provider. The file does not show that the Plan provided notice 
that this service would not be covered. Under Medicare rules, this means this service is considered approved by 
the Plan. Therefore, we decided that the Plan has to hold you harmless for the skin tag removal (11200) 
provided on September 29, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Topotecan & Dexamethasone Sodium Phosphate. 
 
You asked the Plan to pre-approve Topotecan & Dexamethasone Sodium Phosphate. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested drugs are 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Topotecan & Dexamethasone Sodium 
Phosphate. Our reviewer says that the documentation supports that the requested drugs are medically 
reasonable or necessary. Our physician reviewer found the enrollee has advanced neuroendocrine carcinoma 
tumor colon with liver metastases. The documentation supports that the requested use of the drugs is FDA 
approved for the enrollee's diagnosis because this type of neuroendocrine cancer is treated the same as small 
cell lung cancer. Therefore, the enrollee meets criteria for the requested drugs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Topotecan & Dexamethasone Sodium Phosphate have been met. Therefore, we 
decided that the Plan has to pre-approve Topotecan & Dexamethasone Sodium Phosphate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair repair services to be provided by an 
out of network (OON) provider. 
 
You asked the Plan to pre-approve power wheelchair repair services to be provided by an OON provider. You 
say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers 
that are able to provide this care. Therefore, coverage criteria has not been met. 
 
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 
power wheelchair repair services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture. 
 
You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your 
request. The Plan says benefits for this service are only available once every five years. 
 
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 dentures once 
every five years. 
 
Dentures were last received less than five years ago on April 5, 2019. Based on this information, we decided 
that the Plan's rules for coverage of the dentures have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a complete maxillary and mandibular denture.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (01926, 01160) provided on June 10, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the records show that 
the requested anesthesia services were not performed. 
 
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 01926 is "Anesthesia for therapeutic interventional 
radiological procedures involving the arterial system; intracranial, intracardiac, or aortic." The CPT Code 
Manual definition of code 01160 is "Anesthesia for closed procedures involving symphysis pubis or sacroiliac 
joint." 
 
We asked our coding 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 use 
of codes 01926 and 01160 is not supported by the records provided. Our coding reviewer found that the 
operative report documents an Abdominal aortogram, Right lower extremity angiogram, atherectomy and 
balloon angioplasty of the right peroneal artery. CPT codes 01926 and 01160 do not support the services 
performed. 
 
We looked at this coder?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 the services (01926, 01160) provided on June 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lactulose 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 drug is intended for patient self-administration. 
 
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 Lactulose for the enrollee.
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. The Plan denied your request. The Plan says 
specialized care can be provided by in-network providers. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient office consultation (99242) to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve the consultation. You say that you want to have the consultation to see if 
they are willing to help with your pain. You've been to other oral surgeons but they won't take out the implants 
because they do not want to risk it. The Plan denied your request. The Plan says enrollee's must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered 
 
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 
outpatient office consultation (99242) to be provided by an out of network (OON) provider.