Persius/hicric huggingface dataset:
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 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 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 
revision of right knee arthroplasty. 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. The medical record supports a need for physical and 
occupational therapy but it does not support a need for an intensive rehabilitation therapy program. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider. 
 
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 available from network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chemotherapy combination of capecitabine, 
mitomycin, and ondansetron. 
 
You asked the Plan to pre-approve capecitabine, mitomycin, and ondansetron. You say that the enrollee needs 
to start treatment as soon as possible. The Plan denied your request. The Plan says the denial of authorization 
for these drugs is correct, because this combination of drugs is experimental. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 capecitabine, mitomycin, and 
ondansetron. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested 
chemotherapy drug combination. Our physician reviewer found the requested combination of drugs is not 
approved by the Food & Drug Administration (FDA). The requested use for localized bladder cancer is not 
supported in any of the Medicare-approved drug compendia. This use is not indicated, recommended, or 
supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of capecitabine, mitomycin, and ondansetron have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a chemotherapy combination of capecitabine, mitomycin, 
and ondansetron.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve attendant control (CPT Code E2331). 
 
You asked the Plan to pre-approve attendant control. You say that the durable medical equipment is medically 
necessary. 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 attendant control have not been met. The request can be approved 
if your records (office visit notes, test results, treatment) show the enrollee meets Medicare criteria for the 
attendant controller. The records must show the enrollee meet these criteria: The enrollee must not be able to 
operate the power wheelchair and there must be documentation explaining why your caregiver cannot push a 
manual wheelchair for you to use. Therefore, we decided that the Plan does not have to pre-approve attendant 
control (CPT Code E2331).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the psychological services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the OON psychological care. You say that you were told that you would be 
able to continue with this provider on your new plan. You feel that it should be covered since you were 
misinformed and you have a long history with this provider. The Plan denied your request. The Plan says 
although you have a history with the requested provider, your benefit only allows coverage for providers in 
your network and medical group. There are other providers in your group who can manage your condition. 
 
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. There were no medical records provided to 
support that transitional visits until you find a network provider are necessary. 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 psychological services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positioning cushion/pillow/wedge (CPT Code E0190). 
 
You asked the Plan to pre-approve the pillow wedge. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says this item is not covered under Medicare or the Health 
Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve positioning cushion/pillow/wedge (CPT Code E0190).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management services provided to the 
enrollee on December 20, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99239 (1 Unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is "hospital discharge day management, more than 
30 minutes." 
 
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 pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
discharge report did not include documentation that more than 30 minutes of hospital discharge management. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for hospital discharge day management services provided to the enrollee on December 20, 2019.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the cervical spine (72141). 
 
You asked the Plan to pre-approve the MRI. You say that The MRI is medically necessary. The Plan denied 
your request. The Plan says that coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
MRI is medically necessary. Our physician reviewer found the enrollee has known disc disease. Surgical 
intervention is planned. The MRI is supported in the records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have been met. Therefore, we decided that the Plan has to pre-approve 
Magnetic Resonance Imaging (MRI) of the cervical spine (72141).  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on March 16, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that nobody notified you of 
this transport and would have been able to take her yourself. The Plan denied your request. The Plan says you 
were charged this cost sharing 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 $225 
copayment for each ambulance trip. You had an ambulance trip(s). The Plan charged you $225 for these 
services. 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 ambulance services provided on March 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical preparation (15002) provided on January 13, 2020. 
 
You asked the Plan to pay for surgical preparation. You say that this code is separately payable. The Plan 
denied your request. The Plan says this procedure is not documented. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 15002 is surgical preparation or creation of recipient site 
by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar 
contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children. 
 
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 pay for surgical preparation. Our reviewer says that 
this code is not supported. Our physician reviewer found the submitted documentation does not include 
preparation of recipient site. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of surgical preparation have not been met. Therefore, we decided that the Plan 
does not have to pay for surgical preparation (15002) provided on January 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pontics and retainer crown. 
 
You asked the Plan to pre-approve the pontics and retainer crown. The Plan denied your request. The Plan says 
the criteria for coverage has not been met. 
 
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 pontics 
and retainer crown when the services are medically necessary and reasonable.  
 
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 pontics and retainer crown. Our 
reviewer says that the criteria for coverage has not been met. Our physician reviewer found there has been no 
documentation of medical compromise of the enrollee or a neurological disorder that would require the use of a 
fixed appliance. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontics and retainer crown have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the pontics and retainer crown.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the non-sterile gloves (CPT Code A4927). 
 
You asked the Plan to pre-approve the non-sterile gloves. You say that the gloves are medically necessary if 
you are on dialysis. You state this should not have been denied because you are high risk and need gloves 
during this pandemic. The Plan denied your request. The Plan says this item is not covered under Medicare or 
the Health Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
Based on a review of the records, there is no information that you are receiving dialysis (a process for 
removing waste and excess water from the blood) or home health services. Otherwise, Medicare does not cover 
non-reusable items nor items used for hygiene. The item at issue in this appeal does not serve a purpose that is 
primarily medical in nature. This item is available to the general public and would be helpful even to those who 
are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the non-sterile gloves 
(CPT Code A4927).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuriphysiological monitoring (95886, 95907, 95955, and 
95999) provided on January 14, 2019. 
 
You asked the Plan to pay for neuriphysiological monitoring. You say that these codes should be paid. The 
Plan denied your request. The Plan says these codes are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95886 is needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List 
separately in addition to code for primary procedure); 95907nerve conduction studies; 1-2 studies; 95955 is 
electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery); and 95999 is unlisted 
neurological or neuromuscular diagnostic procedure. 
 
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 pay for neuriphysiological monitoring. Our reviewer 
says that these codes are not supported. Our physician reviewer found the opperative report does not support 
CPT 95955, as procedure was not performed during a intracranial procedure (eg. carotid surgery). CPT 95907 
is not supported because the documentation did not include motor and/or sensory nerve conduction studies. The 
service cannot be verified. CPT 95886 is not supported as the record does not show that EMG each extremity, 
complete, five or more studies were performed. Finally, it is inappropriate to bill 95999 to report Train of Four 
testing. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuriphysiological monitoring have not been met. Therefore, we decided that 
the Plan does not have to pay for neuriphysiological monitoring (95886, 95907, 95955, and 95999) provided on 
January 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an enhanced steering performance (ESP) unit and power 
seat elevation feature. 
 
You asked the Plan to pre-approve ESP unit and power seat elevation feature. You say that you are appealing 
based on medical necessity. The Plan denied your request. The Plan says the denial of authorization for these 
items is correct, because an enhanced steering performance unit is not necessary, and a power seat elevation 
feature is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that a power seat elevation feature is non-covered by Medicare. 
 
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 ESP unit and power seat elevation 
feature. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found this unit would exceed the enrollee's medical need. The 
enrollee was already approved for an expandable controller with harness. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ESP unit and power seat elevation feature have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an enhanced steering performance (ESP) unit and power 
seat elevation feature.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that the durable medical equipment is medically 
necessary. The Plan denied your request. The Plan says the enrollee's records show they have not completed the 
necessary face-to-face evaluations to assure  that this device meets but does not exceed the enrollee's need and 
that the enrollee's home provides adequate access between rooms,  maneuvering space, and surfaces for the 
operation of  this scooter. 
 
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 a power scooter have not been met. Review of the file show that 
the enrollee is requesting the scooter for outside of the home and a walker for inside the home. The Medicare 
rules say that if any power operated vehicle (POV) or power wheelchair only for use outside the home, it will 
be denied as noncovered. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve debridement of nail(s) by any method(s); 6 or more 
(CPT Code 11721), destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical 
curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions 
(CPT Code 17110) and arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, 
temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance 
(CPT Code 20605). 
 
You asked the Plan to pre-approve the services. You say that this should not be denied because you were seen 
on January 21, 2020 and were supposed to return in March. The Plan denied your request. The Plan says the 
Plan did not receive any updated notes since this last visit to justify nail debridement. 
 
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 services have not been met. This is because according to the 
Medicare Benefit Policy Manual (Chapter 15, Section 290), Medicare does not cover routine foot care when 
there is no evidence of systemic conditions. Based on a review of the records provided, we see that your last 
visit was on February 20, 2020. Therefore, we decided that the Plan does not have to pre-approve debridement 
of nail(s) by any method(s); 6 or more (CPT Code 11721), destruction (eg, laser surgery, electrosurgery, 
cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular 
proliferative lesions; up to 14 lesions (CPT Code 17110) and arthrocentesis, aspiration and/or injection, 
intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); 
without ultrasound guidance (CPT Code 20605).