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

We decided that the Plan has to pre-approve myocardial perfusion imaging (MPI). 
 
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 that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MPI 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 medically necessary. Our physician reviewer found the enrollee has somewhat atypical 
symptoms of chest discomfort and dyspnea. She has a number of risk factors for coronary artery disease (CAD) 
and intermediate pre-test probability for CAD. Her baseline electrocardiogram (EKG) is abnormal. A standard 
exercise stress test would not be diagnostic to rule out CAD based given this baseline EKG. Given her 
intermediate pre-test probability, the chest symptoms, the baseline EKG abnormalities with the prior non-
diagnostic stress EKG, and the fact that it has been a full three years since her last nuclear MPI study, a 
reassessment for cardiac ischemia is reasonable and 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 been met. Therefore, we decided that the Plan has to pre-
approve myocardial perfusion imaging (MPI).  
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq (J9022). 
 
You asked the Plan to pre-approve Tecentriq. 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 Tecentriq. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found Tecentriq/etoposide is not supported by 
any Compendia or literature for limited stage small cell cancer. Even if extensive, the regimen would not be 
approvable without carboplatin. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tecentriq (J9022).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve these services. You say that you can't be left at home. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 records do not show that skilled 
nursing and skilled therapy services are currently required to effectively provide treatment, care, and/or 
services in order to improve your condition, or to establish/perform a maintenance program to maintain your 
condition and/or prevent deterioration. As the documentation does not clearly reveal that you are receiving 
skilled nursing or skilled therapy services. The requested services do not meet the definition of home health 
aide services. Home health aide services are not reasonable and 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 home health aide services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee is receiving appropriate in-patient acute care and 
does not require transfer to LTACH. 
 
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. The enrollee 
still requires acute hospital level of care services and is receiving appropriate care at the present acute care 
hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital 
where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for LTACH services. 
 
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 long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on August 11, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the 
referring provider is out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physician services provided on August 11, 2020 
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total electric hospital bed. 
 
You asked the Plan to pre-approve the total electric hospital bed. You say that you would like reconsideration 
because you have been waiting a month for this bed. The Plan denied your request. The Plan says total electric 
hospital beds are not considered medically reasonable and necessary by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve the total electric 
hospital bed.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on August 5, 2020. 
 
You asked the Plan to pay for the genetic testing.. You say that you would like reconsideration because the 
services were medically necessary to treat the member. The Plan denied your request. The Plan says this 
service was not billed correctly. 
 
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 test at issue in this appeal, the genetic testing., was requested solely for screening purposes. The 
documentation does not show that the requested pharmacogenomic testing was ordered due to any 
signs/symptoms of a drug reaction. There is no evidence that the testing was provided for therapeutic decision-
making regarding the need for the use of any specific drug. Therefore, we decided that the Plan does not have 
to pay for the genetic testing provided on August 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not meet the requirements for approval. 
 
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 pre-approve the services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you no longer qualify for SNF coverage. 
You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. The 
enrollee is ambulating household distances. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a 
practical matter, can be provided at a lower level of care (ex. home, AL, LTC). 
 
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 continued admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revision of a total knee arthroplasty (27487). 
 
You asked the Plan to pre-approve revision of a total knee arthroplasty. 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 follows Medicare rules. Medicare rules say that Replacement/Revision knee arthroplasty is 
considered reasonable and necessary when specific criteria is 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 revision of a total knee arthroplasty. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found documentation 
does not demonstrate loosening of one or more component, or; fracture or mechanical failure of one or more 
components, or; infection, or; periprosthetic fracture of distal femur, proximal tibia or patella, or; progressive 
or substantial periprosthetic bone loss, or; bearing surface wear with symptomatic synovitis, or; implant or knee 
misalignment, or; knee stiffness/arthrofibrosis, or; tibiofemoral instability, or; extensor mechanism instability. 
Furthermore, there is indication in the documentation that a trial of conservative treatment modalities has been 
attempted. In particular, further details of these treatments along with documentation of failure of the treatment 
is not evidenced. Therefore, this request is not medically reasonable or 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 revision of a total knee arthroplasty have not been met. Therefore, we decided 
that the Plan does not have to pre-approve revision of a total knee arthroplasty (27487).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 31, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider 
is out-of-network with the Plan and authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on July 31, 2020 by 
an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide a therapeutic continuous glucose monitor. 
 
You asked the Plan to provide a therapeutic continuous glucose monitor. You say that the enrollee needs a 
therapeutic continuous glucose monitor. The Plan denied your request. The Plan says criteria is not met for a 
therapeutic continuous glucose monitor. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have 
to provide a therapeutic continuous glucose monitor.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90792) provided 
August 6, 2019. 
 
You asked the Plan to pay for the psychiatric evaluation. You say that you did not receive proper notice of the 
benefit determination, hence, the untimely submission of the claim. You depend on the facility for timely 
notification of patient's insurance coverage. The Plan denied your request. The Plan says the claim was 
received past the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the psychiatric evaluation was not filed until September 8, 2020. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90792) provided August 6, 
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213). 
 
You asked the Plan to pre-approve the dental item. You say that the partial denture is necessary. The Plan 
denied your request. The Plan says partial upper denture is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
partial upper denture (D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 20, 2020 to October 
20, 2020 by an out of network (OON) provider. 
 
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 were rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on August 20, 2020 
to October 20, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a home ventilator for the enrollee. 
 
You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary for the enrollee. 
The Plan denied your request. The Plan says that that ventilators used to provide CPAP or bi-level CPAP 
therapy will be denied as not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is medically reasonable and necessary for the enrollee. The patient has chronic 
respiratory failure consequent to chronic obstructive pulmonary disease. The enrollee has been diagnosed with 
Chronic Hypoxemic Respiratory Failure and Chronic Obstructive Pulmonary Disease. The patient requires a 
Non-Invasive Ventilator when sleeping at home for retention of carbon dioxide as indicated on provided 
arterial blood gas result. Our physician reviewer found that the enrollee's condition meets Medicare criteria for 
a home ventilator. 
 
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 home ventilator have been met. Therefore, we decided that the Plan has to 
pre-approve a home ventilator 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the replacement lead wires for a transcutaneous electrical 
nerve stimulator (TENS) provided on September 22, 2020. 
 
You asked the Plan to pay for the replacement lead wires. You say that this should be covered as it is separately 
payable in addition to A4595. The Plan denied your request. The Plan says this replacement was provided 
earlier than one year after receiving the TENS unit. There is no documentation of the medical necessity of this 
replacement. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement of TENS lead wires (A4557) more 
often than every 12 months would rarely be reasonable and necessary. 
 
Review of the records provided shows that the enrollee received the TENS unit for rental on June 22, 2020. It 
was purchased on August 22, 2020. The replacement lead wire was provided the next month. There is no 
documentation in any of the records provided that justifies that a replacement wire was needed at the time it 
was supplied, just four months after the unit was originally received. Therefore, we decided that the Plan does 
not have to pay for the replacement lead wires for a transcutaneous electrical nerve stimulator (TENS) provided 
on September 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lupron Depot (J1950). 
 
You asked the Plan to pre-approve Lupron Depot. 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 Lupron Depot. 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 Lupron Depot is medically reasonable or necessary or safe and 
effective for the 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 Lupron Depot have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Lupron Depot (J1950).