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

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the abdomen and 
pelvis and a blood count provided on October 15, 2021, by a provider not enrolled in the Medicare program. 
 
You asked the Plan to pay for a CT scan of the abdomen and pelvis and a blood count. You say that the 
services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules 
for payment have not been met because the provider at issue is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan of the 
abdomen and pelvis and a blood count provided on October 15, 2021, by a provider not enrolled in the 
Medicare program.
Appeal type: SNF
Decision: Favorable

 
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 member has not been receiving physical therapy 
and needs Skilled Nursing to gain her strength back. The Plan denied your request. The Plan says the medical services because medical records indicate that the member is not able to follow commands and based on 
current level of function, the services are not reasonable and necessary for treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 The 
members needs may be met a home with supervision and home health services. The member can also receive 
these services at a long-term care facility with part-time skilled services. Our physician reviewer found Based 
on the documentation provided, it is my opinion that the enrollee qualifies for SNF coverage.  The enrollee 
does have documented skilled nursing needs in the form of daily wound care, frequent repositioning and 
maintenance/use of off-loading techniques.  The enrollee does not have documented skilled therapy needs.  
Daily skilled services are required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan does not have to pre-approve 
skilled nursing facility (SNF) care.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for medical services provided on November 13, 2021. 
 
You asked the Plan to pay for the medical services. You say that the claim originally denied for a provider type 
error, so the claim was refiled.  It was then denied as a duplicate in error. The Plan denied your request. The 
Plan says that this claim is a duplicate. 
 
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. Specifically, the Plan's sole rationale for denial is that this claim is a duplicate.  
However, the first time this claim was submitted, the Plan didn't pay it. You contend that you fixed any 
provider error that would have resulted in the original claim submission's denial.  The Plan has failed to address 
this correction.  The Plan has failed to provide any evidence that this new claim is somehow deficient. The 
burden is on the Plan to prove that its denial was correct, and we find that in this case the Plan has not met this 
burden. Therefore, we decided that the Plan has to pay for medical services provided on November 13, 2021.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says they do not have a record from the enrollee's prescriber that shows the enrollee has 
tried Dysport or Xeomin and it has not worked, or the enrollee has medical reasons that prevent them from 
using a preferred drug. The Plan states these preferred drugs require prior authorization. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our physician reviewer 
found the case file does not contain documentation of trial and failure of Dysport or Xeomin. The 
documentation does not support that Dysport or Xeomin would likely be less effective, and/or would likely 
have adverse effects for the enrollee in this case. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Botox.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the breast magnetic resonance imaging (MRI) provided on January 27, 
2022. 
 
You asked the Plan to pay for the breast MRI. You say that the Plan has not provided any background as to 
why this was denied. The Plan denied your request. The Plan says that this service is 
experimental/investigational. 
 
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. Specifically, the Plan's sole denial rationale is that this service is 
experimental/investigational. That is simply not true. National Government Services, the Medicare Part B 
Affiliated Contractor for the State of Illinois specifically has a coverage policy for breast MRIs wherein this 
service is coverable for multiple indications.  The Plan has failed to state if the patient did or did not meet these 
coverage criteria. The Plan has failed to address this existing policy in any way. The Plan has failed to indicate 
if it even reviewed the medical records submitted with your appeal request.  The burden is on the Plan to 
support its denial.  By its failure to address any of these items, we find that the Plan has not met this burden. 
Therefore, we decided that the Plan has to pay for the breast magnetic resonance imaging (MRI) provided on 
January 27, 2022.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 additional home health skilled nursing visits. 
 
You asked the Plan to pre-approve 3 additional home health skilled nursing visits. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 3 additional home health skilled nursing 
visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found you do 
not have documented skilled nursing needs. Your ostomy is established. Blood draws alone are not an 
indication of home health skilled nursing services. As such, the requested home health skilled nursing services 
are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3 additional home health skilled nursing visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 3 additional home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an echocardiogram provided on January 7, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an echocardiogram. You say that the services were rendered in a hospital setting 
and the hospital was responsible to obtain an authorization. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an echocardiogram provided on January 7, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Short-latency somatosensory evoked potential study 
(95938), Neurology and Neuromuscular Procedures, Electromyography Procedures (95861) and Central motor 
evoked potential study (transcranial motor stimulation) (95939) provided on March 21, 2021. 
 
You asked the Plan to pre-approve Short-latency somatosensory evoked potential study, Neurology and 
Neuromuscular Procedures, Electromyography Procedures and Central motor evoked potential study 
(transcranial motor stimulation). You say that Short-latency somatosensory evoked potential study, Neurology 
and Neuromuscular Procedures, Electromyography Procedures and Central motor evoked potential study 
(transcranial motor stimulation) was medically necessary. The Plan denied your request. The Plan says Short-
latency somatosensory evoked potential study, Neurology and Neuromuscular Procedures, Electromyography Procedures and Central motor evoked potential study (transcranial motor stimulation) was 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 Short-latency somatosensory evoked 
potential study, Neurology and Neuromuscular Procedures, Electromyography Procedures and Central motor 
evoked potential study (transcranial motor stimulation). Our reviewer says that Short-latency somatosensory 
evoked potential study, Neurology and Neuromuscular Procedures, Electromyography Procedures and Central 
motor evoked potential study (transcranial motor stimulation) are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the clinical documentation in the case file does not 
support that Short-latency somatosensory evoked potential study (CPT 95938), Neurology and Neuromuscular 
Procedures, Electromyography Procedures (CPT 95861), and Central motor evoked potential study 
(transcranial motor stimulation) (CPT 95939) provided on March 21, 2021 was medically reasonable and 
necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Short-latency somatosensory evoked potential study, Neurology and 
Neuromuscular Procedures, Electromyography Procedures and Central motor evoked potential study 
(transcranial motor stimulation) have not been met. Therefore, we decided that the Plan does not have to pre-
approve Short-latency somatosensory evoked potential study (95938), Neurology and Neuromuscular 
Procedures, Electromyography Procedures (95861) and Central motor evoked potential study (transcranial 
motor stimulation) (95939) provided on March 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options (K0861, E1028, E2620, E0955, E1007, E1012, E2361, E2607, E2377, E2313, E2311). 
 
You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options. You say that the 
requested wheelchair is medically necessary. The Plan denied your request. The Plan says the requested 
wheelchair does not meet criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the 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 a group 3 power wheelchair with 
multiple power options. Our reviewer says that the service is not medically necessary. Our physician reviewer 
found the enrollee has a personal mobility deficit that impairs participation in mobility related activities of 
daily living such as toileting, feeding, grooming and bathing in customary locations within the home. Provided 
records do not document that he is high risk for development of pressure ulcer or requires intermittent 
catheterization for bladder management or has increased muscle tone or spasticity. Records do not document a 
condition preventing 90-degree flexion at the knee or significant lower extremity edema. Provided records 
document that the enrollee has right upper extremity range of motion within functional limits and is able with 
adaptive equipment to dress, bathe and toilet himself thus indicating he has adequate upper extremity strength 
and function to operate the wheelchairs power options with their own switches. 
 
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 group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple 
power options (K0861, E1028, E2620, E0955, E1007, E1012, E2361, E2607, E2377, E2313, E2311).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to reimburse an additional amount for the transplant related lodging, meals and 
transportation, per diem, (S9975) provided from February 8, 2022, to February 11, 2022. 
 
You asked the Plan to reimburse an additional amount for the transplant related mileage. You say that only 
$.05 per mile was reimbursed for your 666.4 miles, for a total of $118.80. You say that you used to receive 
$.50 per mile. You also say that you should have received more. The Plan denied your request. The Plan says 
that the claim processed correctly. 
 
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. Specifically, the file does not substantiate that the reimbursement rate $.18 per 
mile was appropriate in this case. The Internal Revenue Service (IRS) website shows that rate for 2022 is 58.5 
cents. This accounts for not only gas, but tolls and wear and tear on the vehicle and therefore is more 
appropriate. 666.4 miles travelled x 58.5 cents = $389.54. $389.54 - $119.95 already reimbursed = $269.89. 
Therefore, we decided that the Plan has to reimburse an additional $269.89 for the transplant related lodging, 
meals and transportation, per diem, (S9975) provided from February 8, 2022, to February 11, 2022.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Farxiga 10MG tablets (CPT code J8499). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Farxiga is a self-administered drug and does not fall under Part B 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 Farxiga 10MG tablets (CPT 
code J8499).   
Benefits for the medication 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a HomeMade Method weight management program 
subscription purchased on March 24, 2021. 
 
You asked the Plan to pre-approve weight management program. You say that this should be reimbursed under 
the weight management allowance. The Plan denied your request. The Plan says the denial of payment for this 
subscription is correct, because this is not covered by the Plan's weight management reimbursement benefit. 
 The Plan must follow Medicare rules. Medicare rules say that Plans may cover weight management programs 
that provide structured lesson on a weekly basis. The Plan contract says that the Plan covers weight loss 
programs, but does not cover costs for meals/foods, books, videos, scales, or other items or supplies. 
 
We looked at the file and Medicare rules. This program does not fall within Medicares allowable coverage for 
weight management programs, nor the Plans supplemental benefits for weight loss programs. Based on this 
information, we decided that Medicare rules for coverage of weight management program have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a HomeMade Method weight management 
program subscription purchased on March 24, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for lab services provided on November 1, 2021. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment of this claim. The Plan denied your request. The Plan says that the information previously requested 
for this claim was never received. 
 
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. Specifically, the Plan's sole rationale for denial is that "the information 
previously requested for this claim was never received."  The Plan has provided no explanation as to what this 
needed information was.  You submitted medical records with your appeal request.  The Plan has provided no 
evidence that it reviewed these records or that these records failed to support medical necessity of the billed 
services.  The burden is on the Plan to show that its denial was appropriate.  Without providing any evidence 
that the documentation was reviewed and is still deficient, we find that the Plan has not supported its denial. 
Therefore, we decided that the Plan has to pay for lab services provided on November 1, 2021.  
 
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: 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 in the Medicare rules section 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 the 
services are not medically necessary. Our physician reviewer found you do not have documented skilled 
nursing needs or skilled therapy needs. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at 
a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.