Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the office visit services. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent 
to seek out-of-network care. The Plan says that there are equally qualified in-network specialist's available to 
you that can provide the care and treatment you are seeking for your condition. 
 
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 office visit services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a low dose CT scan for lung cancer screening for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that imaging is not supported without details about what led to the test being requested. 
 
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 medically reasonable and necessary. Our physician reviewer found the exam was discussed 
with the enrollee, and was planned in the records. While a written order is not seen in the submitted records, 
there is ample evidence the exam is indicated and should be approved once the order has been received. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
a low dose CT scan for lung cancer screening 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 pre-approve hospital bed, semi-electric (head and foot adjustment), 
with any type side rails, without mattress (CPT Code E0261) and Gel or gel-like pressure pad for mattress, 
standard mattress length and width (CPT Code E0185NU) 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the DME is not 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 DME. Our physician reviewer 
found a semi-electric hospital bed is not medically necessary per LCD: L33820. The documentation does not 
clearly reveal that patient's condition has failed positioning of the bed in ways not feasible in an ordinary bed or 
why positioning of the bed in other ways is not feasible. The documentation does not support a need for an 
immediate change in body position or special attachments that cannot be fixed on an ordinary bed. The 
documentation indicates the physician states the patient needs the head of the bed elevated over 30 degrees due 
to lung disease but it is not clear that the patient failed positioning of the bed in other ways such as pillows or 
wedges. The request for CPT Code E0185NU is not medically necessary for this patient. The documentation 
does not reveal the patient is  completely immobile, has limited mobility or unable to  independently make 
changes in body position significant enough to alleviate pressure and has any stage pressure ulcer on the trunk 
or pelvis. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress 
(CPT Code E0261) and Gel or gel-like pressure pad for mattress, standard mattress length and width (CPT 
Code E0185NU)
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's needs can be met at a lower level of care. 
 
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 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and 
occupational therapy services but based on the medical records provided the patient does not require an 
intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the treatment of root canal obstruction (D3331). 
 
You asked the Plan to pre-approve the treatment of root canal obstruction (D3331). The Plan denied your 
request. The Plan says the service is not a covered benefit. 
 
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 the 
treatment of root canal obstruction (D3331).
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 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 must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current setting. Therefore, this request for LTACH services is not justified and will 
be considered not medically necessary at this time. Transfer to a lower level of care may be considered when 
treatment has finished. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is ready for discharge to rehabilitation 
and will decline if she goes home. You say that home health care would only provide a limited amount of 
physical therapy and that the enrollee would benefit from 3 hours of therapy per day. You say that the enrollee 
is a fall risk and should be under the watch of a provider. The Plan denied your request. The Plan says the 
guidelines for coverage of IRF care have not been met. The Plan says that the enrollee could receive the care 
needed in another setting. 
 
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 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 
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 not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 of 5 requested home health skilled nursing services 
(G0299). 
 
You asked the Plan to pre-approve 3 additional skilled nursing services. You say that the enrollee needs 
additional skilled nursing care. The Plan denied your request. The Plan says rules for additional skilled nursing 
care have not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 3 additional skilled nursing services. 
Our reviewer says that the request for additional skilled nursing visits is not medically necessary. Our physician 
reviewer found the records do not show that the additional skilled nursing services are required to effectively 
provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has had 
prior skilled nursing for disease and medication management and education.  
The enrollee's conditions are chronic and there is no evidence of complex wound care. The enrollee can self-
inject medications. There is no recent updated physician report with an indication that the enrollee requires 
ongoing skilled nursing needs beyond what was approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3 additional skilled nursing services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 3 of 5 requested home health skilled nursing services (G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backup battery. 
 
You asked the Plan to pre-approve the backup battery. You say that this equipment is medically necessary 
because the member has issues with their electricity. The Plan denied your request. The Plan says this is not a 
Medicare covered benefit. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a positive airway pressure device. The battery included with the positive 
airway pressure device serves the same purpose as the backup battery. Therefore, we decided that the Plan does 
not have to pre-approve a backup battery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture (D5212). 
 
You asked the Plan to pre-approve the dental item. You say that you do not agree with the denial. You say that 
the partial denture should be covered. The Plan denied your request. The Plan says dentures are covered once 
every 60 months. The Plan says the frequency limit has been reached. 
 
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 and partial dentures are a covered 
service, the frequency limit of once every 60 months has been reached. The record shows the Plan paid for a 
lower partial denture that you received on March 9, 2016. Therefore, we decided that the Plan does not have to 
pre-approve a lower partial denture (D5212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on June 22, 2020. 
 
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says that 
these services are available from the Plan?s hearing aid provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case.   
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were provided by an out-of-
network provider. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided 
on June 22, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a CT scan of the heart for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the clinical information provided appears to describe a request for screening. 
 
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 medically reasonable and necessary. Our physician reviewer found the enrollee has echo 
evidence of disease in 3 of 4 cardiac valves. As such the risk of coronary artery disease is elevated and CT 
calcium scoring is a non-invasive means with which to attempt to stratify risk. As such, this is not a screening 
test but rather a diagnostic test to supplement the cardiac echo and should be approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
a CT scan of the heart 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit with related services (99214, 20610, J3301) 
provided on November 22, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit with related services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was 
not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 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 office visit with related services (99214, 
20610, J3301) provided on November 22, 2019 by an out of network (OON) provider.  
 
Your complaint about the Plan signing you up for an incorrect primary care physician is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
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. 
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) device. 
 
You asked the Plan to pre-approve a CGM device. 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 CGM devices are covered 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 a CGM device. Our reviewer says that 
the item is not medically necessary. Our physician reviewer found based on the medical records provided there 
 
 
is no documentation that you meet the coverage criteria. You are only performing finger stick glucose testing 
twice daily. The coverage criteria requires testing four or more times a day. 
 
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 CGM device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor (CGM) device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first 
intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), pulp vitality tests (D0460), 
cone beam CT capture and interpretation (D0364), and retreatment of previous root canal therapy (D3346) 
provided on June 17, 2020, by an OON provider. 
 
You asked the Plan to pay for the dental services. You say that you were never advised that this provider was 
OON. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan 
also says that services rendered OON 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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), additional intraoral periapical 
x-ray (D0230), pulp vitality tests (D0460), cone beam CT capture and interpretation (D0364), and retreatment 
of previous root canal therapy (D3346) provided on June 17, 2020, by an OON provider.