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

 
We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0648) provided October 14, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the medical records provided support the necessity of 
the services in dispute. The Plan denied your request. The Plan says there is no evidence of an established 
relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation 
and management service and there is no evidence of a prior telehealth service with the ordering physician as 
required per CMS guidelines. 
 
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 lumbar-sacral orthosis (L0648) provided October 
14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the eyeglasses (CPT code(s): V2020 and V2100) to be 
provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the eyeglasses. You say that you are experiencing difficulty seeing and need 
the eyeglasses in order to perform your job. The Plan denied your request. The Plan says you must use 
providers that are in-network for all 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 
the eyeglasses (CPT code(s): V2020 and V2100) to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has low back pain. The 
requested Superion spacer is experimental in nature, as more research is needed to show safety and efficacy. 
The services are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion spacer.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of the genicular nerves (64454). 
 
You asked the Plan to pre-approve the ablation procedure.. You say that the nerve ablation procedure is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 ablation procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested procedure is considered an investigational procedure that is the subject 
of on-going clinical trials. The service is not currently supported as 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 ablation procedure. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation of the genicular nerves (64454).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot, plastic, silicone or equal, heel stabilizer, prefabricated, 
off-the-shelf, each (CPT code L3170), and ankle foot orthosis (L1971 provided to the enrollee on September 
17, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 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 orthoses have not been met. This enrollee did not receive video or telephonic visit by the ordering 
physician in order to warrant the code(s) billed. Furthermore, there are no claims on file with the ordering 
physician listed in the enrollee's claims history 2019-present. Therefore, we decided that the Plan does not 
have to pay for foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each (CPT code 
L3170), and ankle foot orthosis (L1971 provided to the enrollee on September 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for shoulder surgery. 
 
You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says there is no 
documentation to support the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 inpatient services. Our physician 
reviewer found that the enrollee is medically stable and has been provided medical clearance to undergo this 
elective procedure. There is no documentation provided to support the expectation the enrollee will require a 
greater than 2 midnight stay. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve inpatient hospital services for shoulder surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coagulation factor II (F2), coagulation factor V (F5), 
and MTHFR genetic testing. 
 
You asked the Plan to pre-approve F2, F5, and MTHFR testing. You say that this is continuation of care which 
was denied in error. The Plan denied your request. The Plan says the denial of authorization for this testing is 
correct, because this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that F2, F5, and MTHFR testing are non-covered 
except for pregnant patients.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of F2, F5, and MTHFR testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve coagulation factor II (F2), coagulation factor V (F5), and MTHFR genetic testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are concerned for the enrollee's safety until they 
are stronger and independent with the enrollee's mobility and activities of daily living. The Plan denied your 
request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for a fall and acute on chronic renal failure. Medical problems are stable. There are no complex 
nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the 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 not have to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lumbar-sacral orthosis (CPT code L0650) provided to the 
enrollee on September 17, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 orthosis have not been met. This enrollee did not receive video 
or telephonic visit by the ordering physician in order to warrant the code(s) billed. Furthermore, there are no 
claims on file with the ordering physician listed in the enrollee's claims history 2019-present. Therefore, we 
decided that the Plan does not have to pay for lumbar-sacral orthosis (CPT code L0650) provided to the 
enrollee on September 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services provided on  
September 9, 2020. 
 
You asked the Plan to pay for the skilled nursing facility 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 skilled nursing facility services provided on September 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the current acute care hospital with left knee joint 
injection due to internal prosthesis requiring antibiotics, knee joint revision. Antibiotics are estimated to be 
needed until April 25, 2021. The enrollee requires basic wound care only and vitals appear stable without 
leukocytosis. The enrollee does not require services at the LTACH that are not already available at the current 
facility. The documentation does not support that there are services at the LTACH that the enrollee requires 
that are not already available at the health care setting being offered by the health plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special push wheelchair to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says they agree the enrollee's condition makes a manual wheelchair medically necessary. The 
Plan states the service is available in-network, and there are no extenuating circumstances related to geographic 
access, compelling continuity of care making it medically necessary that future care come only from this 
provider to justify prior authorization of out-of-network benefits. 
 
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 
special push wheelchair to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fillings for teeth # 3 and 14, and the pin retention 
provided from October 27, 2020, to November 3, 2020. 
 
You asked the Plan to pay for the dental services. You say that you received the name of an in network dentist 
from the Plan. You say that that provider was not accepting new patients. You also say that you went to this 
dentist instead. The Plan denied your request. The Plan says the dentist in this case is out of network. The Plan 
says that dental services that you receive out of network 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 and fillings are listed as a covered 
service, dental services that you receive you out of network are not covered. Additionally, regardless of the 
dentist's network status, the pin retention is not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the fillings for teeth # 3 and 14, and the pin retention provided from 
October 27, 2020, to November 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre monitoring system. 
 
You asked the Plan to pre-approve Freestyle Libre. You say that the item should be covered. The Plan denied 
your request. The Plan says you do not meet the criteria for a CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, and six (6) months 
prior to ordering the CGM, your doctor has an in-person visit with you to evaluate your diabetes control and 
determined that criteria above are met. Based on this information, we decided that Medicare rules for coverage 
of Freestyle Libre have not been met. Specifically, you have not had an in-person visit with your physician to 
determine criteria for a CGM has been met. Therefore, we decided that the Plan does not have to pre-approve 
Freestyle Libre monitoring system
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for congestive heart failure and respiratory failure. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 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 not have to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because you 
require these orthotics to walk without pain. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care and enrollee not eligible 
due to active diagnosis of hypertension provided on September 14, 2020 by you, an OON provider. 
 
You asked the Plan to pay for the subsequent nursing facility care and enrollee not eligible due to active 
diagnosis of hypertension. You say that the enrollee has no choice in the medical professional they are seen by 
while in the facility. You also say that you rely on the facility to obtain any necessary authorization. The Plan 
denied your request. The Plan says you are not an in-network provider, and there is no authorization on file. 
 
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 
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 subsequent nursing facility care and enrollee 
not eligible due to active diagnosis of hypertension provided on September 14, 2020 by you, an OON provider.