Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralightweight wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that you would like reconsideration because you 
require a backup wheelchair when your power wheelchair is being repaired. The Plan denied your request. The 
Plan says Medicare does not cover back up wheelchairs. 
 
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 you have power wheelchair. The ultralightweight wheelchair serves the same purpose as 
your power wheelchair. Therefore, we decided that the Plan does not have to pre-approve an ultralightweight 
wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 20, 2019 by an out of network (OON) provider.

You asked the Plan to pay for the medical services. You say that these services were medically necessary. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.

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 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 the medical services provided on December 20, 2019 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (64633, 64634).

You asked the Plan to pre-approve radiofrequency ablation. You say that the patient had sufficient pain relief. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that that repeat denervation procedures involving the same joint will only be considered medically necessary if the patient experienced at least 50% improvement of pain.

We looked at the file and Medicare rules. Although there is conflicting information in the file, the medical records of the enrollee's previous radiofrequency ablation document only 15% pain relief. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (64633, 64634).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this transfer is medically necessary. The 
Plan denied your request. The Plan says Medicare coverage criteria are not 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 the review indicates that the enrollee is a 68-year-old male with a medical history 
which includes hypertension, peripheral vascular disease with a left above the knee amputation, and alcohol 
abuse who was hospitalized on November 11, 2020 following a witnessed cardiac arrest. He had cardiac bypass 
surgery and was intubated until December 24, 2020 when he underwent tracheostomy and PEG insertion. His 
postoperative course has been complicated by acute kidney injury, anoxic brain damage, and heart failure. His 
medical condition stabilized, and he were able to be successfully extubated on December 24, 2020. He 
currently requires supplemental oxygen via his tracheostomy (trach collar) and ongoing tube feeding 
There is no documentation provided necessitating admission to a LTACH. the enrollee does not require 
services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion device. 
 
You asked the Plan to pre-approve a continuous passive motion device. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested 
device. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
The enrollee has not had total knee replacement surgery. Therefore, we decided that the Plan does not have to 
pre-approve a continuous passive motion device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fillings (D2391) for teeth # 4 and 13 provided on July 29, 
2020. 
 
You asked the Plan to pay for the dental services. You say that you were not informed that only 2 fillings are 
covered. You say that you were prepared to pay the $235 that you were initially told the services would cost. 
You also say that you would like all 4 fillings to be paid. The Plan denied your request. The Plan says 2 fillings 
per calendar year are covered. The Plan says that the frequency limit for fillings has been exceeded. 
 
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 frequency limit of 2 fillings per 
calendar year has been exceeded. The record shows that the Plan paid for 2 fillings that you received on the 
same date of service. Therefore, we decided that the Plan does not have to pay for the fillings (D2391) for teeth 
# 4 and 13 provided on July 29, 2020.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a nuclear stress test. We decided that the Plan does not have to 
pre-approve a transthoracic echocardiogram.  
 
You asked the Plan to pre-approve a nuclear stress test and a transthoracic echocardiogram. You say that you 
would like the plan to reconsider their denial. The Plan says that the requested services are 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 a nuclear stress test and a transthoracic 
echocardiogram. Our reviewer says that the requested nuclear stress test is considered medically reasonable and 
necessary and the transthoracic echocardiogram is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has known silent coronary disease with remote CABG, last 
stress test about two years ago, new palpitation symptoms and nine beat non-sustained ventricular tachycardia 
on event monitoring. In this circumstance reevaluation of both LV function and recurrent coronary ischemia 
about two years after the prior exam is reasonable and appropriate.  
 
We decided that the Plan has to pre-approve a nuclear stress test.  
 
Coverage criteria for nuclear stress testing are met since the enrollee has known ischemic disease, no more 
recent evaluation than two years ago and findings concerning for possible coronary ischemia.  
 
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 nuclear stress test have been met. Therefore, we decided that the Plan has to 
pre-approve a nuclear stress test.  
 
 
We also decided that the Plan does not have to pre-approve a transthoracic echocardiogram. 
 
Since both LV function and coronary ischemia can be adequately evaluated with a nuclear stress test this is 
most appropriate and would obviate the need for echocardiography. Coverage for an echocardiogram is not met 
since there is no suspicion for valve disease and LV function can be assessed with the nuclear stress test.  
 
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 transthoracic echocardiogram have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a transthoracic echocardiogram. 
 
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: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that the 
services are medically necessary. Our physician reviewer found the enrollee does not have documented skilled 
nursing needs. The enrollee appears to have skilled therapy needs. The enrollee's prior level of function is 
unclear, but appears to be higher than his current level of function. There is insufficient evidence to show that 
the enrollee has reached a plateau in function/new baseline. Daily skilled services are required to establish a 
maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this 
point, as a practical matter, cannot be provided at a lower level of 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning services (D1110) provided on August 12, 
2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental cleaning services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says you are only covered when services 
are rendered from an in-network provider. 
 
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. The Plan covers the dental 
cleaning services when the services are obtained from in-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. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these dental services. 
Therefore, we decided that the Plan does not have to pay for the dental cleaning services (D1110) provided on 
August 12, 2020, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve home health visit. You say that you would like approval for these services. 
The Plan denied your request. The Plan says there are in-network providers available for these services. 
 
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 
home health services to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says your needs are 
custodial in nature. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF services. Our physician reviewer 
found that from a nursing perspective, you had stable vital signs, and were treated for pain with effect. There 
are no identifiable skilled nursing service needs. Regarding rehab services, you are at an independent to 
supervision level with functional mobility. There are no identifiable skilled therapy service needs. You do not 
require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of 
service criteria for an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction services received on July 6, 2020. 
 
You asked the Plan to pay for the eye refraction services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services received are not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover eye refractions. 
 
We looked at the file and the Plan's rules. While the plan does cover certain vision services, eye refraction is 
specifically not covered. Based on this information, we decided that the Plan's rules for coverage of the eye 
refraction services have not been met. Therefore, we decided that the Plan does not have to pay for the eye 
refraction services received on July 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on June 24, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is included in the 
facility payment. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. Payment for all fees related to this service would have been included under the facility claim. 
Therefore, we decided that the Plan does not have to pay for the services provided on June 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fororal exam (D0120 and D0140) and fillings (D2393) provided on August 5, 2020, August 6, 2020, and September 1, 2020.You asked the Plan to pay fororal exam and fillings. You say that the services should be covered.The Plan denied your request. The Plan says if you see an out-of-network dentist, the coinsurance level will apply to the average negotiated in-network fee schedule (INFS) in your area. You are responsible for the difference between the INFS and dentists' charged fees when visiting an out-of-network dentistMedicare 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. Specifically, you received services from an out-of-network provider. This means you are responsible for the difference in cost between the in-network and out-of-network fees.Therefore, we decided that the Plan does not have to pay fororal exam (D0120 and D0140) and fillings (D2393) provided on August 5, 2020, August 6, 2020, and September 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe VistaSeq hereditary cancer panel.You asked the Plan to pre-approvethe panel. You say that this is medically necessary.The Plan denied your request. The Plan says there is no personal history of cancer.The Plan must follow Medicare rules. Medicare rules say that itemsand 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 panel. Our reviewer says that the requested panel is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the VistaSeq hereditary cancer panel was medically reasonable and necessary for the enrollee in this case.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 panel have not been met.Therefore, we decided that the Plan does not have topre-approvethe VistaSeq hereditary cancer panel.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lead wires (CPT Code A4557) provided on September 
14, 2020, by an out-of-network provider. 
 
You asked the Plan to pay for the lead wires. You say that this service is separately reimbursable. The Plan 
denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the lead wires have not been met. A transcutaneous electrical nerve 
stimulation (TENS) unit has been purchased in the previous 12 months, the lead wires have been denied. The 
rules say that replacement of lead wires more often than every twelve (12) months would rarely be reasonable 
and necessary. Therefore, we decided that the Plan does not have to pay for the lead wires (CPT Code A4557) 
provided on September 14, 2020, by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Farxiga 10 MG tablet. 
 
You asked the Plan to pre-approve Farxiga. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug is not a covered 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 pre-approve Farxiga 10 MG tablet.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from July 23, 2020, 
through July 24, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that you never brought your own 
medications to the hospital before. The Plan denied your request. The Plan says self-administered drugs are not 
a covered benefit per 2020 EOC. 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 self-administered drugs provided from July 23, 2020, through July 24, 2020.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.