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

 
We decided that the Plan does not have to pay for the duplex scan provided on June 15, 2020. 
 
You asked the Plan to pay for the duplex scan. You say that the Plan should pay this claim. The Plan denied 
your request. The Plan says medical records were requested supporting necessity of the duplex scan, but were 
not submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must produce medical records to 
support the services billed. 
 
We looked at this the file and Medicare rules. There are no medical records supporting medical necessity. 
Based on this information, we decided that Medicare rules for coverage of the duplex scan have not been met. 
Therefore, we decided that the Plan does not have to pay for the duplex scan provided on June 15, 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 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 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 services are necessary. Our physician reviewer found the enrollee does not require services at the 
LTACH that are not available at the acute care hospital where they are currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because you were 
showing the most progress in an IRF but were released too early. The Plan denied your request. The Plan says 
the guidelines for coverage of IRF care have not been met. 
 
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 there are no identified problems that need inpatient medical management. 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. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy for decompression of 
neural elements under image guidance CT, cervical or thoracic. 
 
You asked the Plan to pre-approve percutaneous laminotomy/laminectomy for decompression of neural elements under 
image guidance CT, cervical or thoracic. 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 percutaneous laminotomy/laminectomy for decompression of 
neural elements under image guidance CT, cervical or thoracic. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found the requested MILD 
procedure is considered experimental. More research is needed to show safety and efficacy. 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 percutaneous laminotomy/laminectomy for decompression of neural elements under image guidance 
CT, cervical or thoracic have not been met. Therefore, we decided that the Plan does not have to pre-approve 
percutaneous laminotomy/laminectomy for decompression of neural elements under image guidance CT, cervical or 
thoracic.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean alveoloplasty in conjunction with extractions (D7311).You asked the Plan to pre-approvethe dental service. You say that you cannot afford to pay for this procedure.The Plan denied your request. The Plan says an alveoloplasty in conjunction with extractions is not listed as 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 service is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvean alveoloplasty in conjunction with extractions (D7311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device. 
 
You asked the Plan to pay for intermittent limb compression device. You say that the enrollee requires the 
device. The Plan denied your request. The Plan says pneumatic compression devices are not covered by 
Medicare when the documentation does not reflect a covered indication. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression 
device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit for a second opinion to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve the office visit for a second opinion. You say that your provider is not a 
specialist in your medical condition. The Plan denied your request. The Plan says they have in-network 
providers able to treat your medical 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. 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 office visit for a second opinion 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 pay for the diabetic shoes and inserts provided on May 27, 2020. 
 
You asked the Plan to pay for the diabetic shoes and inserts. You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and 
the Proof of Delivery did not include details to corroborate the Delivery Ticket. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order and proof of delivery for the supplies provided in this case. 
There is no physician order, proof of delivery or relevant medical records which support medical necessity for 
the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the diabetic shoes 
and inserts provided on May 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 28, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are 
not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on February 28, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient physical therapy (PT) services rendered on January 8, 
2020. 
 
You asked the Plan to pay for these services. You say that the services should be covered. The Plan denied 
your request. The Plan says that the allowed amount has been reached for therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the allowed amount has been reached for therapy. While 
there is a therapy cap for Medicare, the services may be allowed if medically necessary. The Plan has not 
provided any records from the in-network provider to support that the services were not medically necessary 
and therefore subject to the therapy cap. There is no documentation to support that the services cannot be 
covered. Therefore, we decided that the Plan has to pay for the outpatient physical therapy (PT) services 
rendered on January 8, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature with electrical 
connection. 
 
You asked the Plan to pre-approve power seat elevation feature. You say that you are requesting review based 
on medical necessity. The Plan denied your request. The Plan says the denial of authorization for these items is 
correct, because a power seat elevation feature is non-covered and an electrical connection is non-covered if 
used for a power seat elevation feature. The Plan also says that they have approved coverage for the power 
wheelchair itself and the other requested accessories, so this denial is only for a power seat elevation feature 
and electrical connection. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered 
because it is not primarily medical in nature, and an electrical connection device with the sole function of 
connection for a power seat elevation feature will also be denied as non-covered.  
 
We looked at the file and Medicare rules. These wheelchair accessories are non-covered by Medicare. Based on 
this information, we decided that Medicare rules for coverage of power seat elevation feature have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature with 
electrical connection.
Appeal type: Practitioner Services
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 this is the only doctor that has been very good 
to you. The Plan denied your request. The Plan says the services are available from network providers. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is 
not providing these services and is not making arrangements to provide these services. Therefore, we decided 
that the Plan does not have to pre-approve a referral to an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve Radiofrequency ablation. You say that it is your medical opinion that the 
treatment sought is clinically supported and medically necessary. You have enclosed documentation to support 
medical necessity to justify certification. The Plan denied your request. The Plan says the records do not 
support that the enrollee meets the criteria for the requested criteria. 
 
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 Radiofrequency ablation. 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 neck and low back pain after an MVA in 2010. He 
complains of pain that radiates into both legs as well as weakness in his legs. He underwent RFAs on 9/8/20 
and 10/6/20. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Radiofrequency ablation (RFA).
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 this is medically necessary. The Plan denied 
your request. The Plan says this 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethree periodontal scalings and root planings (D4342 x3).You asked the Plan to pre-approvethe scalings and planings. You say that to eliminate the source of infection, deep scaling and root planing needs to be done.The Plan denied your request. The Plan says this service is not covered under the enrollee's dental benefits plan.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-approvethree periodontal scalings and root planings (D4342 x3)
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 based on the 
records submitted. 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve home health aide services. You say that the enrollee lacks skills to be able to 
care for himself. The Plan denied your request. The Plan says hourly care is more than the reasonable 
frequency, and is considered custodial. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We looked at the file, and Medicare rules. The records do not show that skilled nursing or therapy services 
were requested, or are being provided. Custodial care is not covered. Based on this information, we decided 
that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-
approve home health aide services.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for the physical therapy services rendered on January 6, 2020. 
 
You asked the Plan to pay for these services. You say that the services should be covered. The Plan denied 
your request. The Plan says that the allowed amount for therapy was met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the allowed amount has been reached for therapy. While 
there is a Medicare therapy cap, the services may be allowed if medically necessary. The Plan has not provided 
any medical records to show that the services were not medically necessary and eligible for the therapy cap. 
Therefore, we decided that the Plan has to pay for the physical therapy services rendered on January 6, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need a portable 
concentrator because you lack oxygen while getting groceries or shopping. The Plan denied your request. The 
Plan says you have not tried and failed portable B or liquid oxygen tanks. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home.  
 
We looked at the file and Medicare rules. The record shows your physician says there are no medical 
contraindications or limitations preventing you from utilizing portable tanks or liquid oxygen. You are 
requesting a portable oxygen concentrator for use outside the home.  Based on this information, we decided 
that Medicare rules for coverage of a portable oxygen concentrator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the palonosetron injection provided on February 10, 2020. 
 
You asked the Plan to pay for the palonosetron injection (J2469). You say that the Plan should pay this claim. 
The Plan denied your request. The Plan says this procedure code is incidental to another procedure. 
 
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 J2469 is Injection, palonosetron hcl, 25 mcg, Drugs 
administered other than oral method, chemotherapy drugs. 
 
This drug is an antiemetic associated with chemotherapy. An incidental procedure is not reimbursed separately 
on a claim.  Based on this information, we decided that Medicare rules for coverage of the palonosetron 
injection (J2469) have not been met. Therefore, we decided that the Plan does not have to pay for the 
palonosetron injection provided on February 10, 2020.