Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anesthesia for an upper endoscopy. 
 
You asked the Plan to pre-approve these services. You say that you have had anesthesia for the same procedure 
in the past. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records show that you 
have a history of Barrett's esophagus and colon polyps. You are scheduled for an upper endoscopy. General 
anesthesia for an upper endoscopy may be considered reasonable and necessary for a person over the age of 
seventy, who has mouth or neck abnormalities that increase the risk for airway obstruction, or who is obese 
with a body mass index (BMI) equal to or over forty. The records do not show that you have any of these 
conditions. There is no medical indication for general anesthesia and the services are not reasonable or 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve anesthesia for an upper endoscopy.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy services provided July 
31, 2020 to August 26, 2020. 
 
You asked the Plan to waive the copayment for the PT services. You say that physical therapy at therapy 
facility is listed at $10 copay. Please review and adjust payment for all of your physical therapy. The Plan 
denied your request. The Plan says this claim was processed and the correct copayment applied per the 
Evidence of Coverage. 
 
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 $40 
copayment for physical therapy in an outpatient hospital for Outpatient rehabilitation services.  
 
You have been asked to pay $40 copayment for physical therapy in an outpatient hospital for the PT services. 
the PT services falls within the Outpatient rehabilitation services 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 the physical therapy services provided July 31, 2020 to August 26, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 288 routine transportation trips. 
 
You asked the Plan to pre-approve the 288 additional routine transportation trips. You say that you are on 
dialysis and have no transportation. You say that you have to go to the doctor's 3 times a week. The Plan denied 
your request. The Plan says routine transportation trips beyond the 40 allowed per calendar year will not be 
covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 40 one-way routine transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. The records show that the Plan has 
approved 40 one-way routine transportation trips for you in the 2021 calendar year. Your request is for 
additional routine transportation trips beyond these approved 40, and this request exceeds your benefit 
allowance. Based on this information, we decided that you have exhausted the Plan maximum benefit for 
coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve an 
additional 288 routine transportation trips.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational 
therapy services but based on the medical records provided you do not require an intensive inpatient 
rehabilitation therapy program. There is concern that you will not be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to lethargy 
and confusion. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal mouth guard. 
 
You asked the Plan to pre-approve the dental item. You say that the mouth guard will help you sleep at night 
and prevent you from grinding your teeth. The Plan denied your request. The Plan says the occlusal mouth 
guard 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 an 
occlusal mouth guard.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmented pneumatic compression device for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no records of a basic device trial. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not support that this enrollee has lymphedema of the chest, trunk, or abdomen. 
The enrollee does not have unique characteristics that would indicate the segmented pump over a standard 
pump. There is no documentation of a four-week trial and failure of the standard pump. 
 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a segmented pneumatic compression device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided August 9, 2019, to 
August 10, 2019. 
 
You asked the Plan to pay for the inpatient hospital services. You say that the services provided were medically 
necessary and reasonable. The Plan denied your request. The Plan says the claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the inpatient hospital services was not filed correctly until August 22, 2020. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided August 9, 
2019, to August 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compressor and sleeve appliances (E0652 
and E0667). 
 
You asked the Plan to pre-approve the pneumatic compressor and sleeve appliances. You say that you would 
like reconsideration because this equipment is medically necessary. The Plan denied your request. The Plan 
says the clinical information submitted does not show that the member meets criteria for these items. 
The Plan must follow Medicare rules. Medicare rules say that for E0652 to be covered, a four-week trial of 
conservative therapy demonstrating failed response to treatment with and E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the pneumatic compressor and sleeve appliances have not been met. Specifically, the record does 
not show that the member has undergone a four-week trial of conservative therapy demonstrating failed 
response to treatment with and E0650 or E0651. Therefore, we decided that the Plan does not have to pre-
approve the pneumatic compressor and sleeve appliances (E0652 and E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00142) provided on February 25, 2020. 
 
You asked the Plan to pay for anesthesia services. You say that this should be covered. The Plan denied your 
request. The Plan says this is a duplicate claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that an additional 7 units of CPT code 00142 are not supported in the medical record. The medical 
record only supports 7 units of CPT code 00142, which were previously billed and paid for this date of service 
by the same provider. Based on this information, we decided that Medicare rules for coverage of anesthesia 
services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services 
(00142) provided on February 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray (73100) provided on April 6, 2020. 
 
You asked the Plan to pay for an x-ray. You say that this should be covered. The Plan denied your request. The 
Plan says this was not billed with a necessary modifier. 
 
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, we have confirmed that code an 
73100 has a bundled relationship with code 73110, which was billed by the same provider for the same date of 
service, and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for an x-ray (73100) provided on April 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two preventive procedures (D1999 x2) and periodontal 
maintenance (D4910) provided on July 2, 2020, and July 8, 2020. 
 
You asked the Plan to pay for the preventive procedures and periodontal maintenance. You say that you would 
like to be reimbursed for these services. The Plan denied your request. The Plan says these services are not 
covered under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 pay for the two 
preventive procedures (D1999 x2) and periodontal maintenance (D4910) provided on July 2, 2020, and July 8, 
2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Caris Molecular Intelligence Tumor Profiling services. 
 
You asked the Plan to pre-approve the Caris Molecular Intelligence Tumor Profiling services. You say that the 
requested testing is medically necessary. You say that the requested test will be part of the enrollee's clinical 
treatment plan and the biomarker results will be used to help develop the most appropriate treatment plan. You 
say that the attached clinical history and medical records clearly indicate the need for molecular testing. The 
Plan denied your request. The Plan says the requested test has not been FDA approved for use. The Plan says 
that it is considered experimental and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Caris Molecular Intelligence Tumor 
Profiling services. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has a diagnosis of metastatic adenocarcinoma 
of the rectum. Genetic testing with Ambry cancer next expanded panel was done on October 20, 2020 and was 
negative for pathogenic mutations. Ambry Cancer Next-Expanded panel is a next generation sequencing panel 
that analyzes 77 genes associated with increased risks for brain, breast, colon, ovarian, pancreatic, prostate, 
renal, uterine, and many other cancers. Caris Molecular Intelligence has not been approved by the FDA. 
 
 
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 Caris Molecular Intelligence Tumor Profiling services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Caris Molecular Intelligence Tumor Profiling 
services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this device has deluxe features that exceeds medical need. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is insufficient literature in the peer reviewed publications to assess safety, efficacy, long term 
outcomes or patient management associated with the use of the MyoPro Orthosis for upper extremity 
paralysis/paresis from conditions such as the enrollee's stroke. Therefore, per Social Security Act, Section 1862 
(a)1(A) and the 42 CFR Section 411.15(k), the requested orthosis is not reasonable and necessary for the 
diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The 
MyoPro Orthosis is not the most appropriate available supply or level of service for the enrollee in question 
considering potential benefits to the enrollee.It is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro is not in widespread use 
based on scientific evidence and not the standard of care for post stroke hemiparesis. There is insufficient 
evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this enrollee, 
improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature 
that this device will increase participation in bimanual activities. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro Motion G orthotic device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services (CPT 97012, CPT 97014) provided 
to you on November 13, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
covered when provided by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the chiropractic services (CPT 97012, CPT 97014) provided to you on 
November 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on July 6, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on July 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7140), preventive procedure (D1999), and 
problem focused limited oral evaluation (D0140) provided on August 10, 2020. 
 
You asked the Plan to pay for the extraction, preventive procedure, and problem focused limited oral 
evaluation. You say that you would like these services to be reconsidered. The Plan denied your request. The 
Plan says your maximum allowed for oral exams had been met. The Plan also says that the extraction and 
preventive procedure are not covered by the 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 extraction (D7140) and preventive 
procedure (D1999) are not among those covered under this benefit. The Plan contract also says oral exams are 
limited to 1 (D0120-D0180) every 6 months. The record shows that you received a comprehensive oral 
evaluation (D0150) on February 25, 2020, and your oral exams benefit had been exhausted. Therefore, we 
decided that the Plan does not have to pay for the extraction (D7140), preventive procedure (D1999), and 
problem focused limited oral evaluation (D0140) provided on August 10, 2020.
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 need to leave the hospital and get rehab as soon 
as possible. You say that not having IRF care would seriously jeopardize your health and your ability to regain 
maximum function. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have 
not been met. The Plan says that the enrollee can safely receive the services needed in another setting. 
 
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a fractured hip after a fall. The enrollee's medical conditions are stable.  
 
There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation 
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a 
need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 
program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. 
 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.