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

We decided that the Plan has to pre-approveMagnetic Resonance Imaging (MRI) of the brat.You asked the Plan to pre-approveMRI. You say that this test was recommended by your primary care provider.The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because routine follow-up with mammography is recommended in your clinical situation and this MRI 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 MRI. Our reviewer says that you meet the Medicare criteria for the requested MRI. Our physician reviewer found, given that you are a high risk patient with prior breast cancer and family history of breast cancer, combined with fibrous changes that make screening mammography less effective, an MRI of the breast is medically indicated and reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI have been met.Therefore, we decided that the Plan has to pre-approveMagnetic Resonance Imaging (MRI) of the brat.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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea sleep study (CPT code 95810).You asked the Plan to pre-approveCPT code 95810. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says a sleep study described by CPT code 95811 was already approved and CPT code 95810 is a duplicative procedure.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 95810 is Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist. We looked at the file and Medicare rules. The file shows the Plan has approved coverage of CPT code 95811, which is defined by the CPT Code Manual as Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist. This approved CPTcode includes the services represented in CPT code 95810. Based on this information, we decided that Medicare rules for coverage of the polysomnography services represented by CPT code 95810 have not been met. Therefore, we decided that the Plan does not have to pre-approve the polysomnography servicesrepresented by CPT code 95810.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a compression bra identified with code A6549. 
 
You asked the Plan to pre-approve the bra. You say that this is not medically necessary. The Plan denied your 
request. The Plan says this is not covered by Medicare or the plan. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a compression bra 
identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sensor for a Freestyle Libre continuous glucose 
monitor (CGM). 
 
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 state that a therapeutic CGM and supplies are covered when 
the beneficiary is insulin-treated with multiple (three or more) daily injections of insulin. 
 
We looked at the file and Medicare rules. The file shows that you have a diagnosis of diabetes but are not 
insulin-treated. 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 sensor for a Freestyle Libre 
continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee still actively requires daily medical management, and intensive rehab therapy.The Plan denied your request. The Plan says the enrollee is not able to participate in an intensive rehab program.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physicianreviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee was hospitalized due to shortness of breath due to bilateral pneumonia with acute respiratory failure requiring mechanical ventilation. The hospital course was complicated by the development of renal failure requiring initiation of hemodialysis, and atrial fibrillation with slow heart rate. The enrollee completed IV antibiotics for pneumonia. The complexity of hisnursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Hismedical status does not currently require intensive physician and nursing oversight only in an IRF. The enrolleemay benefit from physical and occupational therapy, but the documentation does not support that the enrollee'sfunctional status requires or can tolerate an intensive rehabilitation therapy program provided in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does nothave to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralight manual wheelchair with elevating leg rests 
(K0005). 
 
You asked the Plan to pre-approve the ultralight manual wheelchair with elevating leg rests. You say that the 
ultralight wheelchair and leg rests are medically necessary. The Plan denied your request. The Plan says rules 
for coverage are not met. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchairs are covered when 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 ultralight manual wheelchair with 
elevating leg rests. Our reviewer says that the requested wheelchair and elevated leg rests are not medically 
necessary. Our physician reviewer found based on the medical records provided there is no documentation that 
the ultra-lightweight wheelchair and elevating leg rests are medically necessary. The available medical records 
do not document that the enrollee requires individualized fitting and adjustments for one or more features such 
as, but not limited to, axle configuration, wheel camber, or seat and back angles which cannot be 
accommodated by a K0001 through K0004 manual wheelchair or that she has a musculoskeletal condition or 
the presence of a cast or brace which prevents 90 degree flexion at the knee or that the enrollee has significant 
edema of the lower extremities that requires an elevating leg rest. 
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 ultralight manual wheelchair with elevating leg rests have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an ultralight manual wheelchair with 
elevating leg rests (K0005).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stair glide repairs. 
 
You asked the Plan to pre-approve the repairs. You say that your stair glide was damaged during home 
renovations. The Plan denied your request. The Plan says the plan is not responsible for covering the cost of 
preventable damage. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve stair glide repairs.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 

We decided that the Plan does not have to pre-approvea power seat elevation feature for a power wheelchair.You asked the Plan to pre-approvethe power seat elevation feature. You say that the accessories are medically necessary.The Plan denied your request. The Plan says a power elevation feature is not a covered item.The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered. We looked at the file and Medicare rules. The requested powerchair accessory is not a covered item. Based on this information, we decided that Medicare rules for coverage of the power seat elevation feature have not been met.Therefore, we decided that the Plan does not have to pre-approvea power seat elevation feature for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Continuous Glucose Monitor (CGM) sensors. 
 
You asked the Plan to pre-approve the CGM sensors. You say that the CGM sensors are medically necessary. 
The Plan denied your request. The Plan says E1399 is not the correct CPT code for the service, additionally 
coverage rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM's and related supplies are covered when the 
beneficiary is insulin-treated with multiple (three or more) daily injections of insulin.  
 
We looked at the file and Medicare rules. The record shows the enrollee uses oral medications to control their 
diabetes and does not use injected insulin. Based on this information, we decided that Medicare rules for 
coverage of the CGM sensors have not been met. Therefore, we decided that the Plan does not have to pre-
approve Continuous Glucose Monitor (CGM) sensors.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CTA scan. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says recommended surveillance is via ultrasound, not CTA. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the documentation does 
not support the medical necessity of the study in question. You have had multiple CTA studies demonstrating a 
37 mm abdominal aortic aneurysm that has been stable since at least 2015. While surveillance is indeed 
indicated, yearly CTAs put you at risk of excessive contrast dye and radiation exposure. The health plan has 
suggested ultrasound surveillance as the appropriate study. This request should be resubmitted as an aortic 
duplex ultrasound for AAA surveillance. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CTA scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99214) provided on  
March 16, 2018. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $10 
copayment for in-network physician and professional services provided at the primary care physician's office.  
 
You have been asked to pay a $10 copayment for the in-network physician services provided at the primary 
care physician's office. 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 office visit (99214) provided 
on March 16, 2018.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on February 27, 2020. 
 
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the 
service at issue. 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 diagnostic radiology services provided on February 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for supervised exercise therapy provided by a 
participating provider on May 7, 2020 to June 11, 2020. 
 
You asked the Plan to waive the copayment for supervised exercise therapy. You say that you do not agree 
with these copayments. The Plan denied your request. The Plan says the correct copayments have been applied. 
 
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 $10 
copayment for supervised exercise therapy.  
 
You have been asked to pay a $10 copayment for supervised exercise therapy. The total amount you are being 
asked to pay is $120 ($10 x 12 visits = $120). Supervised exercise therapy falls within the supervised exercise 
therapy 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 supervised exercise therapy 
provided by a participating provider on May 7, 2020 to June 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist hand orthosis, the knee orthosis and suspension 
sleeve, and the lumbar-sacral orthosis provided on February 21, 2020. 
 
You asked the Plan to pay for the wrist hand orthosis (L3916), the knee orthosis (L1851) and suspension sleeve 
(L2397), and the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary. The Plan 
denied your request. The Plan says rules for telehealth services were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis, the 
knee orthosis and suspension sleeve, and the lumbar-sacral orthosis provided on February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 10, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the 
services at issue. 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 March 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Nitroglycerin, Indomethacin capsules, Famotidine, 
Alum-mag hydroxide, Oxycodone-Acetaminophen, and Pantoprazole provided. 
 
You asked the Plan to pay for the self-administered drugs. You say that you were not informed that you would 
be charged for non-covered drugs. You also say that you would have brought your own medications from 
home. The Plan denied your request. The Plan says these medications are considered self-administered drugs, 
and need to be processed under your Part D 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 Nitroglycerin, Indomethacin 
capsules, Famotidine, Alum-mag hydroxide, Oxycodone-Acetaminophen, and Pantoprazole provided.  
 
Benefits for the Nitroglycerin, Indomethacin capsules, Famotidine, Alum-mag hydroxide, Oxycodone-
Acetaminophen, and Pantoprazole 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on October 17, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. 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 the medical services provided to the enrollee by an out-of-network provider 
on October 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).