Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve prefabricated knee orthosis with elastic material, joints or hinges, 
condylar pads and may include patella control (L1820). 
 
You asked the Plan to pre-approve the orthosis. You say that the records provided should support the necessity 
of the services in dispute. The Plan denied your request. The Plan says that the request for a knee brace does 
not meet medical necessity criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 orthosis. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was diagnosed with a left knee sprain. Physical findings of the left knee included 
pain with flexion and instability. Left knee x-ray showed some spurring anteriorly. A request for a 
prefabricated elastic orthosis with condylar pads and joints was made. In this case the Medicare coverage rules 
require objective signs of instability or laxity which was documented. Therefore, this request for knee orthosis 
meets criteria. 

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 orthosis have been met. Therefore, we decided that the Plan has to pre-
approve prefabricated knee orthosis with elastic material, joints or hinges, condylar pads and may include 
patella control (L1820).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the three surgical extractions, problem focused limited oral 
evaluation, panoramic x-ray, and incision and drainage of abscess provided on November 20, 2019. 
 
You asked the Plan to pay for the extractions, problem focused limited oral evaluation, panoramic x-ray, and 
incision and drainage of abscess. You say that no one at the provider's office ever asked for your insurance. The 
Plan denied your request. The Plan says these services are not covered benefits under your plan. 
 
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 pay for the three 
surgical extractions, problem focused limited oral evaluation, panoramic x-ray, and incision and drainage of 
abscess provided on November 20, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from  October 
10, 2019, to October 31, 2019. 
 
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 this was custodial. 
 
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 were not necessary. Our physician reviewer found the enrollee did not have documented skilled 
nursing or therapy needs. Daily skilled services were not required to establish a maintenance program or to 
prevent deterioration of the enrollee's condition.  The enrollee's care needs at this point were custodial and, as 
a practical matter, could be provided at a lower level of care. 
 
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  October 10, 2019, to October 31, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 8, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this is a duplicate 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied.  
 
We looked at the file and Medicare rules. The records show that the services in question were billed on a 
duplicate claim to one previously processed by the Plan. The records do not show that these services were 
provided twice on the date of service in question. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the 
lab services provided on August 8, 2019.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services provided to the enrollee on November 11, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the services could have been provided in network. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patient's health. The Plan follows the same rules.  
 
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 medically reasonable and 
necessary. Our physician reviewer found the documentation supports the debilitated nature of the enrollee and 
justifies the need for ambulance transport for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
ambulance services provided to the enrollee on November 11, 2019.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on March 7, 2020. 
 
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says this claim is an exact duplicate to a previously processed 
claim. 
 
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 find that CPT code 71045 is not supported in the medical record. Specifically, this claim is an exact 
duplicate to a previously processed claim. The documentation only shows that one x-ray was provided. Based 
on this information, we decided that Medicare rules for coverage of the x-ray services have not been met. 
Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on March 
7, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for physical and occupational therapy services (97110, 97167, 97163, 
97112, 97542, 97530) provided from April 28, 2020, to April 30, 2020. 
 
You asked the Plan to pay for physical and occupational therapy services. You say that these services should be 
covered. The Plan denied your request. The Plan says that these services were not billed with the correct 
modifiers. 
 
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. Though the Plan states that these services were billed with inappropriate 
modifiers, information was not provided on which modifiers are incorrect are why. The issue with the 
modifiers is not clear and no citation was supplied to support the denial. Therefore, we decided that the Plan 
has to pay for physical and occupational therapy services (97110, 97167, 97163, 97112, 97542, 97530) 
provided from April 28, 2020, to April 30, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services rendered on June 16, 2020. 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT codes 77065 and G0279 is 1. You billed 2 units of each of these codes, 
exceeding the MUE. 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 imaging services rendered 
on June 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ketamine (J3490). 
 
You asked the Plan to pre-approve Ketamine. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for 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 Ketamine. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the review has determined that the 
documentation does not support that the ketamine is safe and effective or medically reasonable or necessary for 
you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ketamine have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ketamine (J3490).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on May 29, 2020 and 
May 30, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says the drugs listed are not covered under your Medicare Part B benefit. 
 
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 pay for the self-administered drugs 
provided on May 29, 2020 and May 30, 2020.  
 
Benefits for the self-administered drugs 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services could be provided in another setting, such as an acute rehab 
facility, skilled nursing facility, nursing facility, outpatient setting, or home care. 
 
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 there is no documentation provided requiring admission to a LTACH. The enrollee 
still requires acute hospital level of care services and is receiving appropriate care at the present acute care 
hospital. The review has determined that the enrollee does not require services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. There are no services available at the 
LTACH that the enrollee requires that are not available at the health care setting being offered by the health 
plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis 
and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on May 20, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 drug testing services provided on May 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first responder fees you incurred on December 31, 2019. 
 
You asked the Plan to pay for the fee. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a Medicare Health Plan must disclose to its 
members the benefits offered under the plan including applicable conditions and limitations, premiums and cost 
sharing such as copayments, deductibles and coinsurance.  
 
We looked at the file and Medicare rules. The Plan contract clearly states that first responder fees are not 
covered under any condition. The fees are not covered under Medicare or your health plan. Based on this 
information, we decided that Medicare rules for coverage of the fees have not been met. Therefore, we decided 
that the Plan does not have to pay for the first responder fees you incurred on December 31, 2019.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient stay for surgery. 
 
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 there is a lack of medical necessity for the inpatient setting. 
 
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 does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the documentation in the case file does not identify conditions for which there is 
medical necessity for an inpatient stay for the planned surgery. 
 
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 not been met. Therefore, we decided that the 
Plan does not have to pay for an inpatient stay for surgery.
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 the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says the submitted information does assess mobility limitations or inability to perform ADLs 
or IADLs. 
 
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 the scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation 
does not reveal that your personal mobility deficit interferes with participation in MRADLs in the home. Your 
mobility deficit is currently helped by a manual wheelchair. The documentation is not clear that you would be 
able to safely maneuver the PMD, given your visual deficits. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drug administered in an outpatient 
hospital setting from May 13, 2020, to May 14, 2020. 
 
You asked the Plan to pay for the self-administered drug. You say that you were brought to the hospital's 
emergency room by ambulance. You say that you were never asked to bring your prescription medications with 
you. You also say that this medication could cause seizures if suddenly discontinued. The Plan denied your 
request. The Plan says the drug that you received in an outpatient hospital setting is considered self-
administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug 
plan. The Plan says the requested drug is not covered under 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 pay for the self-administered drug 
administered in an outpatient hospital setting from May 13, 2020, to May 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine eyewear. 
 
You asked the Plan to pre-approve the additional routine eyewear. You say that you lost your only pair of 
eyeglasses and you are unable to function properly without them. You say that without eyeglasses you are not 
able to read or drive. The Plan denied your request. The Plan says your benefit for eyewear is currently 
exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to 1 pair of lenses and frames every 2 years. 
 
We looked at the file and the Plan's rules. The records show that you have already received coverage for 
eyewear within the last 2 years. This means that the requested for additional eyewear would exceed your 
benefit limitation. Based on this information, we decided that the Plan's rules for coverage of the additional 
routine eyewear have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additional routine eyewear.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardiovascular risk assessment provided on 
May 20, 2020. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says comprehensive 
genomic profile testing is limited to one test per specimen. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The testing at issue in this appeal was requested for screening purposes. Medicare does not cover this testing 
for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary 
cardiovascular risk assessment provided on May 20, 2020.