Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that 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 medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital on November 22, 2020 with pneumonia, respiratory failure, sepsis, acute renal failure, 
and encephalopathy. He is receiving acute hospital care, and acute care services have not been denied. The 
documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where she is currently receiving care. There are no required medical services 
identified that are available at the LTACH, that are not available at the current health care setting being offered 
by the health plan. The LTACH services are not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator (E1390) provided on August 27, 
2020. 
 
You asked the Plan to pay for the oxygen concentrator. You say that you were advised you would be 
responsible for a lower copayment. The Plan denied your request. The Plan says based on Medicare billing 
criteria, the claim was billed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
copayment for durable medical equipment.  
 
You have been asked to pay $23 ($115 x 20%) for the oxygen concentrator. An oxygen concentrator falls 
within the durable medical equipment benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay for the oxygen 
concentrator (E1390) provided on August 27, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the medical services. You say that you suffer from stress and depression.  
You say that you have seen this provider in the past and would like to get back into counseling with him. The 
Plan denied your request. The Plan says there are numerous in-network providers available to you to provide 
you with care. 
 
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 
the medical 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 root canal retreatment (coded D3347) for tooth #28. 
 
You asked the Plan to pre-approve the root canal retreatment. You say that this root canal is over 20 years old 
and need to be retreated. You are unable to afford this on your own. The Plan denied your request. The Plan 
says the requested service is not covered under the enrollee's dental supplement. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
root canal retreatment (coded D3347) for tooth #28.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has worsening low back 
pain radiating to the bilateral lower extremities. Current evidence based medical guideline and peer reviewed 
literature do not fully support the spinal decompression device procedure over the ?gold standard? of lumbar 
laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of 
the Vertiflex Superion spacer. The services are not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion spacer.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MI profile (43 genes) for the enrollee. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has had only one line of treatment. 
 
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 testing. Our reviewer says that the 
requested testing is not considered medically reasonable and necessary in this case.
Our physician reviewer found based on the medical records provided there is no documentation that the 
enrollee meets the criteria for MI profile testing to evaluate for fibroblast growth factor receptor mutation with 
the intention of starting therapy with Erdafttinib for metastatic papillary renal cell carcinoma. The National 
Comprehensive Cancer Network does not endorse the use of Erdafttinib for metastatic papillary renal cell 
carcinoma. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an MI profile (43 genes) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed with AutoImmersion 
Therapy Mattress. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has pressure ulcers of the 
buttocks and sacrum. There is no documentation that she requires position of the body in ways not feasible in 
an ordinary bed, frequent or immediate changes in body position, or special attachments that cannot be fixed 
and used in an ordinary bed. The semi-electric hospital bed with AutoImmersion Therapy Mattress is not 
medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a semi-electric hospital bed with AutoImmersion Therapy Mattress.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that criteria for coverage have been 
met. You say that you could get better control of your glucose levels if you had a Free Style Libre with an 
alarm. The Plan denied your request. The Plan says the records do not show that the criteria for coverage have 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that continuous glucose monitors are covered when 
certain medical criteria have been 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 a continuous glucose monitor. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee is not 
taking 3 shots of insulin per day and is not checking blood glucose levels 4 times daily. 
 
 
 
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 continuous glucose monitor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport provided on 
January 14, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that the transfer was a 
decision made by the professionals at the hospital. You say that you shouldn't be obligated to pay for 
subsequent ambulance transport for a hospital transfer. The Plan denied your request. The Plan says the 
copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $195 
copayment per one-way trip for Medicare-covered ground ambulance services. 
 
You have been asked to pay a $195 copayment for the ambulance transport. The ambulance transport falls 
within the "Ambulance services" benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the ambulance transport provided on January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the office visit for a new patient. We decided that the Plan does 
not have to pre-approve an oral surgical splint, 5 office visits for an established patient, a cephalogram, and an 
orthopantogram.  
 
You asked the Plan to pre-approve the outpatient services. You say that treating the tempomandibular joint is 
medical in nature and has nothing to do with teeth. You also say that the structures in the denial are not what 
are being treated. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically 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 the outpatient services. Our reviewer 
says that the requested services are not medically necessary. Our physician reviewer found the provided 
records are inadequate to support the enrollee's diagnosis of bilateral temporomandubular disorder. 
 
 
 
We decided that the Plan has to pre-approve the office visit for a new patient.  
 
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 outpatient services. Our reviewer 
says that the requested services are not medically necessary. Our physician reviewer found the provided 
records are inadequate to support the enrollee's diagnosis of bilateral temporomandubular disorder. The initial 
evaluation and management service is necessary to determine a proper diagnosis. Therefore, we decided that 
the Plan has to pre-approve the office visit for a new patient.  
 
We also decided that the Plan does not have to pre-approve an oral surgical splint, 5 office visits for an 
established patient, a cephalogram, and an orthopantogram. 
 
The reviewer found that the provided documentation does not allow for a full evaluation of the proposed 
diagnosis. The reviewer found that there is insufficient clinical evaluation or documentation to properly assess 
the situation and obtain a proper and comprehensive diagnosis. Therefore, the reviewer found that the 
remianing services are not medically reasonable or necessary. Therefore, we decided that the Plan does not 
have to pre-approve an oral surgical splint, 5 office visits for an established patient, a cephalogram, and an 
orthopantogram. 
 
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 and adjustable height over-the-bed table. 
 
You asked the Plan to pre-approve over-the-bed table. You say that this over-the-bed table with height 
adjustment is necessary for your everyday life. The Plan denied your request. The Plan says the denial of 
authorization for this item is correct, because this item is not primarily medical in nature and is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve and adjustable height over-the-bed table.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nitro walker identified with code E1399. 
 
You asked the Plan to pre-approve a nitro walker identified with code E1399. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested walker is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items identified with code E1399 are 
miscellaneous items that would not otherwise be identified with another code.  
 
We looked at the file and Medicare rules. Review of the file shows that the code being requested is for durable 
medical equipment, miscellaneous. This is the incorrect code for the requested item. The plan has stated that 
they will cover a heavy duty walker identified with code E0147. Based on this information, we decided that 
Medicare rules for coverage of a nitro walker identified with code E1399 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a nitro walker identified with code E1399.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing provided on November 26, 2019. 
 
You asked the Plan to pay for the testing services. You say that the medical records support medical necessity 
of the performed service. The Plan denied your request. The Plan says the testing was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the 
documentation in the beneficiary's medical documentation. 
 
The file shows that Macula Risk testing was provided. We find that the testing is not supported in the medical 
records. The records show that the enrollee has stable macular degeneration in the left eye and persistent 
macular degeneration in the right eye. The records do not indicate the results of the testing would be used to 
determine a specific treatment strategy or diagnosis. This testing is not covered by Medicare for screening 
purposes.  Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab testing provided on November 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synthroid 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 Medicare says Part B programs can only provide limited benefits for prescription drugs. 
 
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 Synthroid for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the genicular nerves. 
 
You asked the Plan to pre-approve radiofrequency ablation of the genicular nerves. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve radiofrequency ablation of the genicular 
nerves. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has bilateral osteoarthritis of the knees. The 
enrollee had intra-articular trials of Euflexxa and Depo-Medrol. The enrollee had diagnostic genicular nerve 
blocks. The requested procedure is still considered experimental/investigational and is the subject of on-going 
clinical trials. Therefore, the enrollee does not meet 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 radiofrequency ablation of the genicular nerves have not been met. Therefore, 
we decided that the Plan does not have to pre-approve radiofrequency ablation of the genicular nerves.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis coded L1851 and the addition to lower 
extremity orthosis coded L2397 provided on May 26, 2020. 
 
You asked the Plan to pay for the knee orthosis and the addition to lower extremity orthosis. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the items billed are 
not supported by the documentation. 
 
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 L1851 is knee orthosis (ko), single upright, thigh and 
calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, 
with or without varus/valgus adjustment, prefabricated, off-the-shelf. The CPT Code Manual definition of code 
L2397 is addition to lower extremity orthosis, suspension sleeve.  
 
We find that CPT codes L1851 and L2397 are not supported in the medical record. Specifically, the 
documentation submitted does not indicate that a knee orthosis (KO), single upright, thigh and calf, with 
adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or 
without varus/valgus adjustment, prefabricated, off-the-shelf was fitted or dispensed to the enrollee.  
 
 
 
 
Therefore, code L1851 cannot be verified. The documentation submitted does not indicate that a suspension 
sleeve was fitted or dispensed to the enrollee. Therefore, code L2397 cannot be verified. Based on this 
information, we decided that Medicare rules for coverage of the knee orthosis and the addition to lower 
extremity orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the knee 
orthosis coded L1851 and the addition to lower extremity orthosis coded L2397 provided on May 26, 2020.