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

We decided that the Plan has to pay for air ambulance transportation provided on July 14, 2020.
You asked the Plan to pay for air ambulance transport. You say that the enrollee did require ambulance transportation. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because the enrollee could have been transported by other means such as ground ambulance or another type of motor vehicle.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 air ambulance transport. Our reviewer says that this air ambulance service meets the Medicare criteria for payment. Our physician reviewer found the mode of transportation was necessary as the enrollee was deemed a code stroke and urgent intervention was potentially needed, the negative workup does not mean that this transportation was not indicated. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of air ambulance transport have been met. Therefore, we decided that the Plan has to pay for air ambulance transportation provided on July 14, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to backdate a prior authorization and/or pay 10 months rental for a wheelchair provided to the enrollee staring on April 25, 2019.

You asked the Plan to pay for 10 months of wheelchair rental services provided to the enrollee starting on April 25, 2019. You say that Medicare allows 13 months of payments and that the Plan has only paid 3 months. You say that the enrollee has had the wheelchair since April 2019, and you should receive the full 13 months of payments since you are still servicing the enrollee. 

The Plan states Plan contract show DME requires prior authorization. As a plan provider, you should have requested prior authorization prior to the date of issue of the equipment, which you state was April 25, 2019. The Plan denied your request to back date the prior authorization. The Plan approved prior authorization for 3 months. The Plan notes that the enrollee has paid for 13 months rental and cannot be expected to make further payments. The Plan further notes the enrollee cannot be held responsible for the error of a provider in delaying the request for initial prior authorization a year after delivering the equipment on April 25, 2019.  

Medicare rules say that Plans can require enrollees to get prior authorization. The contract with the Plan says that DME requires prior authorization. The prior authorization form shows you did not request authorization for this equipment until October 22, 2020 and it was marked as "continued". There is no record showing you requested prior authorization before issuing the equipment to the enrollee in April of 2019. It should also be noted that the physician order provided for review with your appeal shows it was signed on April 9, 2020. There is no explanation in your appeal as to why over a year passed before prior authorization was requested. As a Plan contract provider, you have an agreement with the Plan that you will follow all of the Plan rules for providing durable medical equipment and services to the enrollee and will accept those payments issued by the Plan. The Plan is correct, the enrollee cannot be held responsible for a provider's error in obtaining prior authorization and assuring their claims are paid correctly. The Plan reports the enrollee has made 13 payments. 

As a Plan provider, you do not have appeal rights with the IRE for payment. You presented this as a pre-service appeal, for 13 months of payment. The Plan paid 3 months; however, the Plan is not required to backdate a prior authorization or make "future" payments for a service that has already occurred and for a service the enrollee has already paid for. Therefore, we decided that the Plan does not have to pay 10 months rental for a walker provided to the enrollee staring on April 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a TENS unit and garments and supplies provided to the 
enrollee on June 5, 2020. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a Medicare-covered benefit for chronic back/neck pain/radiculopathy. 
 
The Plan must follow Medicare rules. Medicare rules say that a TENS unit can be covered for enrollees in a 
clinical study. 
  
There is no evidence of enrollment in an approved clinical study. 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 a TENS unit and garments and supplies provided to the enrollee on June 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain/ceramic crown and core buildup. 
 
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 covered. 
 
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 
porcelain/ceramic crown and core buildup.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the abdomen for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary and beneficial to the 
enrollee's health. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found whereas MRCP may 
have value in addressing the enrollee's ductal status, residual stone disease, and suspected liver disease, 
previously ordered ultrasound and CT scans may be sufficient in providing similar information. Approval of 
MRCP is not medically appropriate without assessing ultrasound findings, and whether the pre-
approved CT scan was performed and with what results. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the abdomen for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH). 
 
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 you appear to be in the acute phase of illness, and needs most likely can be 
in the current setting. 
 
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 you are currently undergoing treatment at an ACH for CoViD-19. You are not 
intubated/ventilated. There is no evidence that you require services that are not currently available. As 
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring you to 
the LTACH. You can remain at the current ACH until such time no acute services are required. You can then 
be transferred/discharged to a lower level of care for any ongoing long term care needs. 
 
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).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a problem-focused oral evaluation (D0140) and bitewing x-
rays (D0270) provided on September 2, 2020. 
 
You asked the Plan to pay for a problem-focused oral evaluation and bitewing x-rays. You say that these are 
covered services. The Plan denied your request. The Plan says these services are covered once a year. 
 
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 only 
covered once a year. The record shows that you previously received these services on January 28, 2020. 
Therefore, we decided that the Plan does not have to pay for a problem-focused oral evaluation (D0140) and 
bitewing x-rays (D0270) provided on September 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation system and steering perform 
unit. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) and power 
standing feature (E2301) are non-covered because they are not primarily medical in nature. The rules say that a 
harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the 
operation of an expandable controller. 
 
We looked at the file and Medicare rules. The requested power seat elevation system is denied by Medicare as 
not primarily medical in nature. The steering perform unit is included in the already approved expandable 
controller with harness. 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 the power seat 
elevation system and steering perform unit.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve removal of intrauterine device (IUD) and placement of new IUD. 
 
You asked the Plan to pre-approve removal of intrauterine device (IUD) and placement of new IUD. You say 
that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the 
requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that only medically necessary services are 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 removal of intrauterine device (IUD) 
and placement of new IUD. Our reviewer says that the documentation does support that the requested services 
are medically reasonable and necessary. Our physician reviewer found the enrollee has a history of heavy 
menstrual bleeding currently treated with the levonorgestrel IUD. The enrollee has a past medical history of 
transient ischemic attacks, epilepsy, anxiety and depression. The health plan does not cover contraception but 
does cover treatment for medical disorders. The enrollee is not a candidate for estrogen-containing 
medications. The documentation supports that the requested levonorgestrel IUD is for the continuation of the 
treatment of heavy menstrual bleeding. Therefore, the request is for a covered treatment of an illness. The 
ancillary benefit of providing contraception is irrelevant. Therefore, the enrollee meets criteria for the requested 
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 removal of intrauterine device (IUD) and placement of new IUD have been met. 
Therefore, we decided that the Plan has to pre-approve removal of intrauterine device (IUD) and placement of 
new IUD.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 31, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says your plan 
has limited out-of-network coverage. 
 
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 did not pre-approve the 
physicians services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat radiofrequency ablation (RFA) of the facet 
joints. 
 
You asked the Plan to pre-approve the repeat RFA procedure. You say that it is felt that this treatment is 
needed as she obtained relief from the prior RFA. The Plan denied your request. The Plan says there is not 
documentation that the enrollee's pain was relieved by 50% for six months. 
 
The Plan follows Medicare rules. Medicare rules say that repeat RFA for facet joints may only be covered if 
the prior RFA produced at least 50% pain relief.  
 
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 repeat RFA procedure. Our 
reviewer says that the documentation does not support that criteria are met for a repeat RFA. Our physician 
reviewer found this enrollee has chronic back pain. She is has had Anterior L5-S1 fusion and a laminectomy. 
She is taking Norco and Carisoprodol for pain. She had Bilateral L4-L5 RFA on 1/16/20. The request is for 
repeat RFA at that level. However, there is no documentation of the degree and duration of pain relief from that 
procedure and/or change in daily living activities/ medication use. The lack of documentation of the duration 
and degree of pain relief from the RFA in Jan 2020 does not meet the criteria of the LCD. Therefore, absent 
adequate documentation at this point, the request is considered 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 the repeat RFA procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a repeat radiofrequency ablation (RFA) of the facet joints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transluminal balloon angioplasty (37248) provided May 12, 
2020. 
 
You asked the Plan to pay for a transluminal balloon angioplasty. You say that you would like reconsideration 
based on the medical records provided. The Plan denied your request. The Plan says the documentation does 
not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 a transluminal balloon angioplasty. Our 
reviewer says that the billed code is not supported by the medical records. Our physician reviewer found the 
medical records provided do not include sufficient documentation to validate that a transluminal balloon 
angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision 
and interpretation necessary to perform the angioplasty within the same vein; initial vein was performed. 
 
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 transluminal balloon angioplasty have not been met. Therefore, we decided 
that the Plan does not have to pay for a transluminal balloon angioplasty (37248) provided May 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids to be provided by an out of network 
provider. 
 
You asked the Plan to pre-approve hearing aids from the out of network provider. You say that the provider has 
superior hearing aids compared to other suppliers. The Plan denied your request. The Plan says there are 
multiple in network providers in the service area. 
 
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 
hearing aids to be provided by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a regimen of pemetrexed, carboplatin, and 
pembrolizumab. 
 
You asked the Plan to pre-approve a regimen of pemetrexed, carboplatin, and pembrolizumab. You say that the 
enrollee needs these drugs. The Plan denied your request. The Plan says this treatment order is not 
recommended. 
 
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 a regimen of pemetrexed, carboplatin, 
and pembrolizumab. Our reviewer says that the criteria for coverage of the requested drugs have not been met. 
Our physician reviewer found the submitted documentation indicates that the enrollee's lung cancer was 
negative for EGFR, ALK, ROS1 and BRAF. She was treated with the requested combination. In the spring of 
2020, she had stable disease and was put on Pembrolizumab monotherapy, but her cancer has progressed on 
Pembrolizumab. The requested use is not FDA approved or supported in any of the CMS approved compendia. 
Therefore, the submitted documentation does not support that the requested drug combination in medically 
reasonable and necessary 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 a regimen of pemetrexed, carboplatin, and pembrolizumab have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a regimen of pemetrexed, carboplatin, and 
pembrolizumab.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation provided on July 17, 2020. 
 
You asked the Plan to pay for ambulance transport. You say that the Plan approved transportation to your home 
from rehabilitation, and you needed to go to your doctor for a check-up. The Plan denied your request. The 
Plan says the denial of payment for this service is correct, because ambulance transportation to a doctor's office 
is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctor?s office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctor?s office. 
Therefore, we decided that the Plan does not have to pay for ambulance transportation provided on July 17, 
2020.