Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. 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 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 based on the documentation provided, the health plan's denial of LTACH coverage 
should be upheld. The patient is currently undergoing treatment at an ACH following a motor vehicle collision. 
The patient was intubated/ventilated and subsequently received a tracheotomy. The patient has since been 
weaned from the ventilator to a tracheotomy collar. There is no evidence that the patient requires services that 
are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no 
advantage in transferring the patient to the LTACH. The patient can remain at the current ACH until such time 
no acute services are required. The patient can then be transferred/discharged to a lower level of care for any 
ongoing LTC needs. 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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implanted neuroelectrodes (63650). 
 
You asked the Plan to pre-approve the implant. You say that the implant is medically necessary. The Plan 
denied your request. The Plan says rules for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that implanted electrodes are only covered when 
medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the implant. Our reviewer says that the 
requested neurostimulator implants are not medically necessary. Our physician reviewer found Implanted 
electrodes for back pain and arachnioiditis remain experimental. More research is needed to show safety and 
efficacy. 
 
 
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 implant have not been met. Therefore, we decided that the Plan does not 
have to pre-approve implanted neuroelectrodes (63650).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (86077) provided on August 5, 2020. 
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied 
your request. The Plan says the enrollee was inpatient for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Place of 
service codes are used to identify facilities. POS 21 indicates Inpatient Hospital and 22 indicates On Campus-
Outpatient Hospital. 
 
We find that the billing of this service is not supported. This was billed with POS code 22, but the record 
indicates this was provided during an inpatient stay. Based on this information, we decided that Medicare rules 
for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for laboratory services (86077) provided on August 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kyphoplasty. 
 
You asked the Plan to pre-approve Kyphoplasty. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Kyphoplasty is only covered for certain indications. 
 
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 Kyphoplasty. Our reviewer says that 
the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the enrollee presents with complaints of back pain following a fall in the bath tub in 
mid-September. There is imaging evidence of a T11 burst fracture which had retropulsed fragments and a 
deformed thecal sac with a residual AP canal diameter of approximately 5 mm.  
 
 
 
There was associated cord deformity without edema. There is reported radiographic evidence of a T11 burst 
fracture with 75% loss of height. Under consideration is a request for kyphoplasty at T11. This enrollee does 
not have a diagnosis, condition and/or symptoms that meet the Medicare criteria for coverage of kyphoplasty 
(in the setting of a burst fracture and less than 1/3 of the original vertebral height.) Therefore, kyphoplasty 
would not be considered the standard of care or medically reasonable and necessary for treatment of the 
enrollee's 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 Kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Kyphoplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a folding wheeled walker and a seat attachment walker 
to be provided by the out-of-network provider. 
 
You asked the Plan to pre-approve the folding wheeled walker and a seat attachment walker. The Plan denied 
your request. The Plan says this service is available in-network. 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, or unique medically-recognized qualifications of the requested out-of-network 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 at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a folding wheeled 
walker and a seat attachment walker to be provided by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enbrel. 
 
You asked the Plan to pre-approve the Enbrel. You say that the drug being requested is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not have Part D coverage with the Plan. The 
Plan says that the drug being requested is not covered under Part B. 
 
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 Enbrel.  
 
Benefits for the Enbrel may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve 3D conformal radiation therapy with 4500Gy dose given 25 
fractions with image-guided radiation therapy (IGRT) followed up high-dose rate brachytherapy. 
 
You asked the Plan to pre-approve the radiation therapy as requested. You say that it is felt that this service is 
necessary and should be covered. The Plan denied your request. The Plan says that this case was partially 
denied due to lack of medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 radiation therapy as requested. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found this enrollee has a diagnosis of endometrial cancer and is not eligible for surgery 
due to high-risk co-morbidities. At issue is treatment with 3D conformal radiation with IGRT. 3D conformal 
radiotherapy is well within accepted standards (and considered the standard of care with IMRT and proton 
therapy being considered more advanced forms of radiotherapy that should be justified with a dosimetric need. 
As neither proton therapy nor IMRT are being requested here, the only issue that is disputable is the need for IGRT. 
 
IGRT is a means to improve set-up accuracy.   IGRT uses daily image guidance to help localize the target so as 
to minimize normal tissue dosing. Specifically, IGRT allows accuracy of treatment delivery, so when 
generating a planning target margin, the margins can be reduced, and thus allow reduction in the volume of 
normal tissues exposed to radiation.  
 
In general, with IMRT, IGRT is considered standard of care (with the technical component bundled together 
with IMRT). For 3D radiation, arguably the same principles apply with IGRT being used to optimize 
positioning. With no specific rationale for IGRT provided in the case records, it seems as though IGRT is being 
offered as routine practice. This poses the challenging question of whether IGRT is a standard of care approach 
with pelvic radiation when treating with definitive (curative) intent. As IGRT could potentially be used to 
minimize bowel exposure in this patient, and can be considered an accepted standard of care, our reviewer feels 
that medical necessity criteria are met. 
 
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 radiation therapy as requested have been met. Therefore, we decided that the 
Plan has to pre-approve 3D conformal radiation therapy with 4500Gy dose given 25 fractions with image-
guided radiation therapy (IGRT) followed up high-dose rate brachytherapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on June 29, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you received a breast exam from 
a nurse and did not see a physician. You feel that the claim is not accurate. The Plan denied your request. The 
Plan says the claims were processed correctly and you are being charged the correct amount. 
 
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 $50 
copayment for specialist visits.  
 
You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's office visits 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 a specialist visit provided on June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve core buildup, including any pins when required. You say that the service is 
medically necessary. The Plan denied your request. The Plan says this is not a covered service. 
 
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 core 
buildup, including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the midface reconstruction surgery (21143). 
 
You asked the Plan to pre-approve the surgical service. You say that the enrollee has a history of 
tempomandibular joint dysfunction. You say that the enrollee is in constant pain, especially when eating. You 
also say that the enrollee has tried pain medications, muscle relaxers, anti-inflammatories, and ice with no 
clinical effects. The Plan denied your request. The Plan says this surgery is not considered medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 
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 surgical service. Our reviewer says 
that the requested service is not medically necessary. Our physician reviewer found the provided 
documentation shows that a recent workup indicates normal tempomandibular joint (TMJ), posterior occlusion 
and an open anterior bite. The reviewer found that he rules of coverage indicated that orthognathic surgery is 
not covered for developmental conditions of the face and jaw that causes an overbite, cross-bite, teeth not 
aligning correctly or similar irregularities of the teeth. Therefore, the reviewer found that the requested service 
is not medically reasonable or 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 surgical service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the midface reconstruction surgery (21143).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on May 18, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim should be submitted to Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physician services provided to the enrollee on May 18, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for physical therapy provided from August 3, 
2020, through August 27, 2020. 
 
You asked the Plan to reduce the copayment for physical therapy. You say that therapy was done at a rehab 
location not a hospital. You say that the copayment should be $10. The Plan denied your request. The Plan says 
the copayments applied correctly. 
 
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 $40 
copayment for physical therapy at an in-network outpatient hospital. 
 
You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is 
$320 ($40/visit x 8 visits = $320). Physical therapy falls within the "Outpatient rehabilitation services" benefit 
category. The records show the physical therapy was billed by the hospital. 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 reduce the copayment for physical therapy provided from August 3, 2020, through August 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve disposable under pads. 
 
You asked the Plan to pre-approve disposable under pads. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says disposable under pads are not covered by Medicare or 
the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve disposable under pads.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered wheelchair. 
 
You asked the Plan to pre-approve a powered wheelchair. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says you do not meet Medicare criteria. 
 
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.  
 
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs and your 
condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
powered wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that it is very necessary for you to have this type of 
item. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
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 are not diabetic but you have other 
conditions. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve molecular pathology testing to be provided by the out-
of-network provider. 
 
You asked the Plan to pre-approve the molecular pathology testing to be provided by the out-of-network 
provider. The Plan denied your request. The Plan says the services should be approved and performed by an in-
network lab. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve molecular 
pathology testing to be provided by the out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 physical therapy (PT) visits (97110). 
 
You asked the Plan to pre-approve 4 PT visits. 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 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 4 PT 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 based on the medical records provided there is no documentation that 
the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. On 
December 7, 2020 the enrollee requested discharge from physical therapy to continue her home exercise 
program on her own. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 4 physical therapy (PT) visits (97110).