Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on May 14, 2020. 
 
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says 
authorization is required for services provided by out-of-network providers. 
 
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 chiropractic services provided on May 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 15, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 find that the ambulance services are not supported in the medical record. Specifically, a sequela S code) 
was the primary, first listed or principal diagnosis listed on the claim. The claim was billed with S32.19XS 
(Other fracture of sacrum, sequela) A Sequela code cannot be listed as the primary diagnosis. Based on this 
information, we decided that Medicare rules for coverage of the ambulance services have not been met. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on May 15, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says you have some limitations of weight shift, which is why a manual wheelchair with 
tilt in space was recommended. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found you have a 
personal mobility deficit, but the documentation does not support that you are neglected and your MRADLS 
are currently not being met at your current facility that has 24/7 staff to assist. The documentation does not 
sufficiently support why your mobility deficit is unable to be helped by the use of a manual wheelchair given 
24/7 staff assist. The documentation does not indicate that you require a ventilator mounted to the wheelchair. 
The patient is noted to be at risk for a pressure ulcer as he has weight shifting difficulty. The documentation 
does not indicate that he uses intermittent catheterization. The documentation does not indicate an Ashworth 
scale that determines the grade of his spasticity or objective evaluation of spasticity.  and whether this power 
seating system is needed to manage spasticity. The mobility limitation is due to a neurological condition 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair and accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided by a 
participating provider on May 14, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you have had this issue before. 
You say that you would like this squared away. The Plan denied your request. The Plan says the correct 
copayment has 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 $30 
copayment for doctor visits/specialist.  
 
You have been asked to pay a $30 copayment for specialist services. The correct copayment has been applied. 
Specialist services fall within the doctor visits/specialist 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 specialist services provided by a participating provider on May 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Myomo robotic assisted device. 
 
You asked the Plan to pre-approve the device. You say that the enrollee's disability can only increase from 
inevitable overuse syndrome to the right arm. The Plan denied your request. The Plan says medical studies 
have not proven that this device is helpful for treatment of the health problem. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the literature is insufficient in terms out effectiveness and safety of this device for the enrollee's 
condition. At this time the requested orthosis is not proven to be more beneficial for treatment of the enrollee's 
medical condition than any available standard therapy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Myomo robotic assisted device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on May 20, 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 May 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve TwoCal enteral formula. 
 
You asked the Plan to pre-approve the formula. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medical records show that nutrition is taken by mouth. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan 
does not have to pre-approve TwoCal enteral formula.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two custom fabricated ankle-foot orthoses for the 
enrollee. 
 
You asked the Plan to pre-approve the orthoses. You say that this is medically necessary. The Plan denied your 
request. The Plan says the provider's statement regarding ankle weakness is not supported by any objective 
measurements. 
 
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 orthoses. Our reviewer says that the 
requested orthoses are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation indicates that the enrollee is ambulatory, but the documentation is conflicting if the 
enrollee has weakness or deformity of the foot and ankle. The enrollee's muscle motor exam was 5/5 and 
therefore there is no objective evidence of weakness on physical examination. The documentation is not clear 
that the enrollee requires stabilization for medical reasons or requires this orthosis to  benefit functionally. The 
enrollee has normal muscle strength in the legs and feet bilaterally, is able to heel and toe walk without 
difficulty, arise from a seated position independently, and has no focal motor or sensory deficit. Given the 
conflicting documentation and documented objective 5/5 strength the patient does not meet the criteria. 
 
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 orthoses have not been met. Therefore, we decided that the Plan does not 
have to pre-approve two custom fabricated ankle-foot orthoses for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says the notes do not show that the enrollee is unable to move around with a walker or 
cane. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the 
documentation does not reveal a personal mobility deficit that impairs participation in MRADLs in the home. 
You can ambulate without an assistive device. The documentation does indicate that you could safely operate 
this power wheelchair in the home due to the lack of an appropriate ramp. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pulpal debridement (D3221), cone beam CT capture 
and interpretation (D0364), and treatment of root canal obstruction (D3331). 
 
You asked the Plan to pre-approve the pulpal debridement, cone beam CT, and treatment of root canal 
obstruction. You say that you would like to appeal these services. The Plan denied your request. The Plan says 
these services are not covered under your benefit package. 
 
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 
pulpal debridement (D3221), cone beam CT capture and interpretation (D0364), and treatment of root canal 
obstruction (D3331).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injection (ESI) with imaging guidance 
(62321). 
 
You asked the Plan to pre-approve epidural steroid injection with imaging guidance. You say that you are in 
severe pain every day. You are currently on the highest dosage of Gabapentin. You had received an epidural 
steroid injection in the past and it helped you significantly. The Plan denied your request. The Plan says the 
requested procedure is not supported for nerve pain after shingles. 
 
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 epidural steroid injection with imaging 
guidance. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the review indicates that the enrollee has post-herpetic 
neuralgia. Her provider has requested an epidural steroid injection with imaging guidance. Per the coverage 
criteria, an epidural steroid injection (ESI) performed with ultrasound guidance is considered experimental, 
investigational, or unproven for the treatment of post-herpetic neuralgia. The review has determined that the 
medical records provided do not meet the requirements listed in the LCD for Medicare coverage. The requested 
epidural steroid injection with imaging guidance (62321) is not medically necessary for this enrollee 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 epidural steroid injection with imaging guidance have not been met. Therefore, 
we decided that the Plan does not have to pre-approve epidural steroid injection (ESI) with imaging guidance 
(62321).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) services. 
 
You asked the Plan to pre-approve the MRI services. You say that the records provided support that the 
requested MRI services are medically necessary. The Plan denied your request. The Plan says that the 
requested MRI services are not medically necessary and no physical therapy is documented. 
 
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 services. Our reviewer says 
that the requested MRI is medically reasonable and necessary. Our physician reviewer found the enrollee has 
known neck lesions involving the cord and presented with radicular pain. Our physician reviewer found that the 
presence of radicular pain and known cervical spine pathology makes an MRI of the cervical spine 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 the MRI services have been met. Therefore, we decided that the Plan has to pre-
approve magnetic resonance imaging (MRI) services.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that the enrollee's balance is 
not 100% and his quadricep muscles are still weak. You say that the enrollee would benefit from further 
therapy. The Plan denied your request. The Plan says additional visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 10 additional physical therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found that the enrollee has had extensive 
therapy and was trained in a home exercise program. Our reviewer says that the unique skills of a professional 
therapist are not required to safely and effectively provide ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says a four-wheeled walker can be recommended. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation 
does not reveal a personal mobility deficit that impairs participation in MRADLs in the home. Your mobility 
deficit is able to be helped by a four-wheeled walker, per the DME consultant evaluation. The documentation 
does not reveal that you can safely maneuver the scooter in your home, due to a lack of space. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a white colored filling. 
 
You asked the Plan to pay for the filling. You say that the filling is medically necessary. The Plan denied your 
request. The Plan says this type of filling 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 pay for a white 
colored filling.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rollator walker for the enrollee. 
 
You asked the Plan to pre-approve the walker. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medical notes received do not support the need for this. 
 
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 walker. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation is unclear whether the enrollee can safely use the current walker. It is unclear if the 
current walker resolves his mobility deficit. The physician progress note states that the enrollee "leans his 
whole weight on the walker" but it is not clear whether the walker itself is not appropriate for the enrollee. It is 
not clear that the walker is nonfunctional or perhaps the enrollee would benefit from an alternative assistive 
device over the requested rollator. There is no objective detailed neuromuscular exam and mobility evaluation 
from a qualified medical professional indicating that the enrollee requires the specifically requested rollator 
walker or whether he can resolve his current mobility deficit safely with repairs to his current walker. Without 
specific information on these findings the request for a new rollator walker cannot be considered safe 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 walker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a rollator walker for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for an out-of-network neurosurgery 
consultation 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says medically necessary care is 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 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 
a referral for an out-of-network neurosurgery consultation