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

 
We decided that the Plan does not have to waive the copayment for the bone density study (77080) provided on 
June 22, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment was applied correctly to the 
service provided. 
 
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 each Medicare-covered x-ray.  
 
You have been asked to pay a $40 copayment for the Medicare-covered x-ray provided. 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 the bone density study (77080) provided on June 22, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an office visit (99213) provided by the physician on April 9, 
2020. 
 
You asked the Plan to pay for an office visit. You say that the physician is a different specialty than 
other providers who provided services on this date. The Plan denied your request. The Plan says the physician
is in the same group practice as another doctor, who also billed an office visit on this date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that while physicians in the same group practice who 
are in the same specialty must bill and be paid as though they were a single physician, physicians in the same 
group practice but who are in different specialties may bill and be paid without regard to their membership in 
the same group. 
 
We looked at the file and Medicare rules. While another physician in the same group practice did bill an office 
visit on this date of service, the record shows that the physicians at issue were of different specialties. 
Therefore, the office visits may be billed and paid separately. Based on this information, we decided that 
Medicare rules for coverage of an office visit have been met. Therefore, we decided that the Plan has to pay for 
an office visit (99213) provided by the physician on April 9, 2020.  
 
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: 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. The Plan denied your request. The Plan says the enrollee does not 
require any specialized skills or equipment for therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found 
that the enrollee was admitted to the acute hospital for a total knee replacement. His medical problems are 
stable. The complexity of his nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation 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. The medical record supports a need for physical and occupational therapy, but it 
does not support a need for an intensive rehabilitation therapy program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the basivertebral 
nerve. 
 
You asked the Plan to pre-approve RFA of the basivertebral nerve. 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 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 RFA of the basivertebral nerve. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has chronic low back pain. The enrollee has degenerative 
changes in L5 and S1 vertebrae. This is considered an experimental/ investigational procedure. The enrollee is 
not enrolled in a clinical trial. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA of the basivertebral nerve have not been met. Therefore, we decided that 
the Plan does not have to pre-approve radiofrequency ablation (RFA) of the basivertebral nerve.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ankle/foot orthosis identified with code L1970 and 
addition identified with code L2820. 
 
You asked the Plan to pre-approve an ankle/foot orthosis and addition. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested items are not medically 
necessary. 
 
 
 
The Plan follows Medicare rules. Medicare rules say that ankle/foot orthoses are 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 an ankle/foot orthosis and addition. Our 
reviewer says that the documentation does not support that the requested items are medically reasonable or 
necessary. Our physician reviewer found while the documentation does support planus deformity and the 
enrollee is ambulatory, the documentation does not support weakness or instability on physical exam. The 
enrollee does not require stabilization for medical reasons. Therefore, the enrollee does not meet criteria for the 
requested items. In addition, since the orthosis is not covered, the requested addition is not covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ankle/foot orthosis and addition have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an ankle/foot orthosis identified with code L1970 and addition 
identified with code L2820.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the medical services. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent 
to seek out-of-network care. The Plan says there are in-network providers available to you that can provide the 
care you are requesting. 
 
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 medical services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lidoderm Dis 5%. 
 
You asked the Plan to pre-approve Lidoderm Dis 5%. You say that the medication is necessary. The Plan 
denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate 
pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Lidoderm Dis 5%.  
 
Benefits for Lidoderm Dis 5% 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says the enrollee is at baseline function.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee was admitted to the acute hospital for weakness and increasing mobility problems. He is living at home,and is receiving home health services. His medical problems are stable. The complexity of hisnursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a reasonable expectation that this enrolleewill be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex scan of lower extremity arteries or arterial 
bypass grafts. 
 
You asked the Plan to pre-approve a duplex scan. 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 duplex scans are 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 a duplex scan. Our reviewer says that 
the documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found you have no documented lower extremity vascular disease, no documented 
claudication symptoms in the clinic note dated July 30, 2020, no documented lower extremity physical exam 
abnormalities and normal screening ankle: brachial indices bilaterally. Therefore, you do not meet criteria for 
the requested services. 
 
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 duplex scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a duplex scan of lower extremity arteries or arterial bypass grafts.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have 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 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing 
services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely 
and effectively provide medically necessary and reasonable treatment only in a SNF. The enrollee is near 
baseline function and does not require skilled therapy services with the specialized skill, knowledge and 
judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable 
treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination 
of these services) on a "daily basis" in a SNF. As a practical matter, this enrollee does not require the necessary 
services on an inpatient basis, in a skilled nursing facility 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve physical therapy. You say that the enrollee will need post-operative physical 
therapy. You say that the therapy is medically necessary to aid in recovering and he needs therapy closer to his 
residence. The Plan denied your request. The Plan says services are available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers and that plans must 
make care accessible to enrollees. 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 contract providers 
located within reasonable distance and travel time 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 physical therapy to be provided by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed tomographic (CT) colonography, screening,
including image postprocessing.
You asked the Plan to pre-approve Computed tomographic (CT) colonography, screening, including image
postprocessing. 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 Computed tomographic (CT) colonography,
screening, including image postprocessing 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 Computed tomographic (CT)
colonography, screening, including image postprocessing. Our reviewer says that the documentation does not
support that the requested services are medically reasonable or necessary. Our physician reviewer found you
had a recent colonoscopy which identified colonic adenomata. In recent meta-analysis the specificity of CT
colonography in screening for CRC was high, although it decreased with decreasing diameter of polyps to be
detected. Of concern in Appellant's setting of limit prep, the sensitivity of CT colonography for the detection of
polyps < 6 mm in diameter was low and heterogeneous. The main factors contributing to a greater sensitivity
of CT colonography were the inclusion of only populations with an average CRC risk and colonic insufflation
with CO2. The documentation supports that you are no longer considered average risk by virtue of his history
of colon adenomatous polyp(s). CT colonography in his case may serve only a bridge to the next colonoscopy.
Optimally, repeat colonoscopy with a pristine prep, is the next test of choice here. Therefore, you do not meet
criteria for the requested services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Computed tomographic (CT) colonography, screening, including image
postprocessing have not been met. Therefore, we decided that the Plan does not have to pre-approve Computed
tomographic (CT) colonography, screening, including image postprocessing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additions identified with code L5629 and L5647. 
 
You asked the Plan to pre-approve the additions. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that additions identified with codes L5629 and L5647 
are non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the additions have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the additions identified with code L5629 and L5647.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Three Wheel Power scooter (K0800). 
 
You asked the Plan to pre-approve the Power scooter. You say that the scooter is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 patients 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 Power scooter. Our reviewer says 
that the power scooter is not medically necessary. Our physician reviewer found the documentation does not 
reveal that the patient has a personal mobility deficit that impairs participation in MRADLs in the home. The 
patient's mobility deficit is currently helped by a prosthesis and is not clear why the patient is unable to use a 
manual wheelchair or walker. The documentation does not reveal that the patient can safely maneuver the PMD 
in all the rooms in the home for MRADLs as the bathroom and bedroom are not accessible. 
 
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 Power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Three Wheel Power scooter (K0800).
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 your leg has become shorter after hip surgery 
making it uncomfortable while you walk. 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: 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 power wheelchair. You say that you would like reconsideration because 
you are unable to stand or walk for more than 30 seconds and cannot breathe when walking to the car. The Plan 
denied your request. The Plan says you have not had a face-to-face evaluation. 
 
The Plan follows Medicare rules. Medicare rules say that the written order prior to delivery (WOPD)for the 
base item may only be written after the completion of the face-to-face encounter. 
 
The file does not show that you have had a face-to-face encounter regarding the power 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 power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Continuous Positive Airway Pressure (CPAP). 
 
You asked the Plan to pre-approve CPAP. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that CPAP 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 CPAP. Our reviewer says that the 
documentation does not support that the requested device is medically reasonable or necessary. Our physician 
reviewer found the enrollee had a home sleep test in November 2019 and was prescribed CPAP. There is no 
documentation of a provider visit to evaluate the results of treatment, and there is no summary of compliance 
with the device. Therefore, the enrollee does not meet criteria for the requested continued CPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPAP have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Continuous Positive Airway Pressure (CPAP).