Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the replacement of a power wheelchair and accessories. 
 
You asked the Plan to pre-approve the replacement of a power wheelchair and accessories. You say that the 
items are medically necessary. The Plan denied your request. The Plan says the notes from the vendor show 
that this wheelchair can be repaired, and that repair costs are less than replacement. A replacement power 
wheelchair is not indicated as current power wheelchair is less than 5 years old, and is therefore not passed 
expected reasonable useful lifetime. 
 
The Plan must follow Medicare rules. Medicare rules say that he reasonable useful lifetime of durable medical 
equipment is determined through program instructions. In the absence of program instructions, A/B MACS (B) 
may determine the reasonable useful lifetime of equipment, but in no case can it be less than 5 years. 
Computation of the useful lifetime is based on when the equipment is delivered to the beneficiary, not the age 
of the equipment. Replacement due to wear is not covered during the reasonable useful lifetime of the 
equipment. During the reasonable useful lifetime, Medicare does cover repair up to the cost of replacement (but 
not actual replacement) for medically necessary equipment owned by the beneficiary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the replacement of a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the replacement of a power wheelchair and accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Genesight Psychotropic testing panel provided on 
October 7, 2021. 
 
You asked the Plan to pre-approve the Genesight Psychotropic testing panel. You say that this testing service 
should be covered. The Plan denied your request. The Plan says there is not sufficient evidence to support this 
testing is medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that combinatorial PGx tests, such as GeneSight, are 
not clearly shown to be more beneficial in drug selection than usual prescribing methods. Therefore, we 
decided that the Plan does not have to pre-approve the Genesight Psychotropic testing panel provided on 
October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6750) for teeth # 20 and 22, and a 
pontic (D6240) for tooth # 21. 
 
You asked the Plan to pre-approve a fixed bridge. You say that this is medically necessary. You also say that 
you were told the services were covered. The Plan denied your request. The Plan says the claim denied 
correctly. 
 
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 fixed bridge is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
retainer crowns (D6750) for teeth # 20 and 22, and a pontic (D6240) for tooth # 21.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair van transportation. 
 
You asked the Plan to pre-approve wheelchair van transportation. You say that you need this transportation 
because the hip replacement was on March 15 and the blood work and x-ray was on March 8. The Plan denied 
your request. The Plan says you do not have a condition that would endanger your health if you did not travel 
by ambulance, thus non-emergency ambulance transportation services are not considered reasonable and 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we 
decided that the Plan does not have to pre-approve wheelchair van transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
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 criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the you do not treat with insulin 
three or more times per day. 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 a continuous 
glucose monitor (CGM).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continuation of SNF care from April 22, 2022, forward. 
 
You asked the Plan to pre-approve SNF care. You say that you cannot walk and are a fall risk and can injure 
yourself. The Plan denied your request. The Plan says that the stay is not medically necessary based on SNF 
criteria. 
 
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 physician reviewer 
found while the provided documentation is confusing, it is my opinion that you do qualify for SNF coverage. 
You do not have documented skilled nursing needs. You do have documented skilled therapy needs. You did 
not receive SNF therapy evaluations until April 19, 2022, when you were shown to be making improvements 
compared to when you were in the hospital on April 9, 2022.  There is insufficient documentation to show that 
you have reached a plateau in function. A period of daily skilled services is required to establish a maintenance 
program, prevent deterioration of your condition and clearly establish your baseline/potential. 
 
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 has to pre-approve continuation of 
SNF care from April 22, 2022, forward.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 fractions of intensity-modulated radiation therapy 
(IMRT)/image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IMRT/IGRT. You say that the enrollee needs this for whole brain radiation. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this 
is 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 IMRT/IGRT. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found given that published studies have not shown a benefit to hippocampal avoidance with whole-
brain radiotherapy for small cell lung cancer, coupled with lack of consensus guidelines supporting this 
treatment, the disputed IMRT would not be in accordance with accepted standards 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 IMRT/IGRT have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 10 fractions of intensity-modulated radiation therapy (IMRT)/image-guided radiation 
therapy (IGRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for out-of-network 
care have not been met. 
 
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 semi-electric hospital bed (E0260) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four prefabricated abutments (D6056 x4) and four 
abutment supported porcelain fused to metal crowns (D6060 x4). 
 
You asked the Plan to pre-approve the prefabricated abutments and abutment supported porcelain fused to 
metal crowns. You say that the enrollee's existing implants need to be restored with abutments and crowns. 
You also say that if they are not restored, it can lead to infection and bone loss over time. The Plan denied your 
request. The Plan says these services are not covered under your benefit 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 pre-approve four 
prefabricated abutments (D6056 x4) and four abutment supported porcelain fused to metal crowns (D6060 x4).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on September 17, 2021. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
the enrollee needed the transportation because she could not go on her own. The Plan denied your request. The 
Plan says an authorization to cover these services is required and not on file for the non-participating provider. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary, and prior 
authorization is required for non-emergency transportation. The Plan follows the same rules.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the non-emergency ambulance transportation and ground mileage have not been met. Therefore, 
we decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on September 17, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve right saphenous vein endovenous ablation with Venaseal with 
foam for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case.  Our physician reviewer found all of the coverage criteria are met. There is satisfactory documentation of 
symptoms severe enough to impact daily activities with satisfactory documentation of failed efforts at 
conservative therapy including compression stockings for more than six months. There is documentation of 
satisfactory arterial perfusion to the lower extremities bilaterally. The degree of reflux in the vein to be treated 
is noted as is the diameter of greater than 4 mm. The planned treatment is reasonable and 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 the services have been met. Therefore, we decided that the Plan has to pre-
approve right saphenous vein endovenous ablation with Venaseal with foam for the enrollee.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a temporary implantable nitinol device (iTIND) with 
cystourethroscopy. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary for prostate symptoms 
of frequent urination. The Plan denied your request. The Plan says a review of the current medical literature 
does not consider this service to be standard medical treatment. 
 
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 iTIND procedure is not considered  medically reasonable and necessary in this case. A review of the 
current medical literature does not consider this service to be standard medical treatment. Further studies are 
needed to evaluate the durability of TIND outcomes over a longer follow-up, to better define the indications of 
this approach, and to demonstrate the advantages of second-generation device over the first. 
 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 temporary implantable nitinol device (iTIND) with cystourethroscopy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine 
for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has been no treatment for lower back pain for at least six weeks. 
 
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 
requested MRI is not medically reasonable or necessary. Our physician reviewer found there was an MRI of 
the lumbar spine on 9/10/19, at which time the multi-degenerative changes were described including 
degenerative retrolisthesis of L5 on S1. No neuro deficit is documented in the records. There are no plain films, 
and no explanation of symptom change, since the MRI of 9/10/19. Absent a red flag, and absent a six week trial 
of physical therapy or further information concerning significant symptom change, the medical necessity of the 
requested MRI has not been established. 
 
 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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lumbar spine for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening testing services. 
 
You asked the Plan to pay for screening testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this is not a Medicare covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for screening testing 
services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that the enrollee needs the CGM to monitor blood 
sugars at home. The Plan denied your request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not treat with 
insulin. 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 a Freestyle Libre continuous glucose 
monitor (CGM).
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 be a great candidate. The Plan denied 
your request. The Plan says you do not require full time access to a rehabilitation physician. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found 
that you were admitted to the acute care hospital for surgical management of cellulitis of the feet. Your medical 
problems are stable. While you have a need for physical and/or occupational therapy, there is no documentation 
of a need for an intensive rehabilitation program.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on July 16, 2021. 
 You asked the Plan to pay for the outpatient hospital services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says this claim includes a Pass-
Through Device that has not been billed with the required procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that C1734 should always be billed with CPT codes 
27870, 28715, 28725 and 28705. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient hospital services have not been met. Specifically, this claim was billed with a pass-
through device but not billed with the appropriate procedure code. Therefore, we decided that the Plan does not 
have to pay for the outpatient hospital services provided on July 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
(D6010). 
 
You asked the Plan to pre-approve an endosteal implant. You say that you believe this is the best course of 
action for your teeth. You also say that you feel the dentures are not working and are a hassle for you. The Plan 
denied your request. The Plan says this service is not covered under your benefit package. 
 
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 pre-approve a 
surgical placement of implant body: endosteal implant (D6010).