Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic body radiotherapy services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has symptomatic prostate 
issues. The Plan denied your request. The Plan says that alternate treatment options were not discussed. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 requested services. Our physician 
reviewer found that several retrospective studies, and recent randomized studies, have investigated the addition 
of pelvic radiation therapy to the primary site in those with metastatic prostate cancer. For this case, the 
enrollee is being offered stereotactic body radiotherapy services (SBRT).  It is clear that radiotherapy to the 
prostate is a standard of care approach. Arguably SBRT is more cost-effective than a 20-fraction IMRT plan, 
with perhaps equivalent or superior outcomes. It is slightly more costly than a 6-fraction IMRT plan, though 
arguably a 5-fraction SBRT plan is very similar to a 6-fraction IMRT plan. As a 5-frcation SBRT would seem 
to be an accepted approach (extrapolating from the 6-fraction regimen used for those with oligometastatic 
disease and emerging data for those with high-risk non-metastatic disease), the standard medical necessity 
criteria are met. 
 
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 requested services have been met. Therefore, we decided that the Plan has to 
pre-approve stereotactic body radiotherapy services.  
 
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: Favorable

 
We decided that the Plan has to waive the copayment for a specialist office visit on May 23, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says that the cost share has been applied 
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 Plan did not include the correct Evidence of Coverage (EOC) 
in the original case file and there was no response to our request for the correct EOC. As a result, we are unable 
to verify the correct cost share was applied.  Therefore, we decided that the Plan has to waive the copayment 
for a specialist office visit on May 23, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a motorized scooter. 
 
You asked the Plan to pre-approve a motorized scooter. You say that the requested motorized scooter is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a 
motorized scooter. 
 
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 motorized scooter. Our reviewer says 
that the enrollee does not meet criteria for a motorized scooter. Our physician reviewer found the enrollee is 
with a medical history of asthma, obesity, spinal stenosis, knee osteoarthritis, diabetes mellitus type II and 
atrial fibrillation. A clinical progress note dated August 19, 2022 indicated that the enrollee was recently 
hospitalized for atrial fibrillation. A clinical progress note dated July 8, 2022 indicated that the enrollee has difficulty ambulating. She uses a walker to assist in ambulation. She was receiving home physical therapy. 
Documentation from her hospitalization indicated that the enrollee was ambulating 120 feet with a walker. 
 
The current documentation indicates that the enrollee can complete her mobility related activities of daily 
living with a walker. There is no indication or evaluation that the enrollee can safely use the requested power 
mobility device or that her home can accommodate it. There is no documentation regarding the enrollees level 
of function in terms of performing daily activities and insufficient documentation regarding her motor strength 
and range of motion. Therefore, the power mobility device is not 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 a motorized scooter have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a motorized scooter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure codes 88360 and 88381) 
provided to the enrollee on January 17, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the professional interpretation of a diagnostic test must be separately billed with modifier  26 
by the interpreting physician.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 88360 and 88381 is not supported in the medical record. Specifically, modifier 26 was 
required for these codes. Based on this information, we decided that Medicare rules for coverage of the services 
have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (procedure 
codes 88360 and 88381) provided to the enrollee on January 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry services 
(93228 and 93229). 
 
You asked the Plan to pre-approve the external mobile cardiovascular telemetry services. You say that your 
doctor wants you to wear a 24-hour heart monitor to catch your heart palpitation episodes. The Plan denied 
your request. The Plan says this request not medically necessary because your records show you do not have 
documentation in the medical records sent from your provider that the use of a 24-hour ambulatory 
electrocardiogram is unlikely to capture and record the dysrhythmia. The Plan also says there is no 
documentation of anticoagulation therapy or atrial fibrillation. 
 
The Plan follows Medicare rules. Medicare rules say that uses of real-time, outpatient cardiac telemetry listed 
in the Medicare rules section of this letter are considered medically reasonable and 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 external mobile cardiovascular 
telemetry services. Our reviewer says that these services are not reasonable and necessary. Our physician 
reviewer found the enrollee had a history of palpitations, and this was the stated indication for a mobile cardiac 
outpatient telemetry (MCOT) authorization. As such, guidelines would not support a need for MCOT 
monitoring in this setting. Our reviewer also found that there was insufficient documentation to support the 
medical necessity for an MCOT monitor in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the external mobile cardiovascular telemetry services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry 
services (93228 and 93229).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approved a Dexcom G6 sensor. 
 
You asked the Plan to pre-approved a Dexcom G6 sensor. The Plan denied your request. The Plan says the 
coverage criteria 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 use insulin with at least three daily administrations, 
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 assess 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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approved a 
Dexcom G6 sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve seat lift mechanism. You say that you need this chair to be more 
comfortable when returning from dialysis. The Plan denied your request. The Plan says you do not meet the 
Medicare criteria for this device. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
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 seat lift mechanism. Our reviewer says 
that you do not meet the Medicare criteria for a seat lift mechanism. Our physician reviewer found the 
documentation does not reveal objective imaging evidence of severe arthritis hip/knee or a neuromuscular 
disease. A seat lift is not likely to affect your condition or arrest/slow deterioration of your condition. The 
records do not show that you are totally incapable of standing from a chair in the home. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of seat lift mechanism have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a seat lift mechanism.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the stabilization device insertion. 
 
You asked the Plan to pre-approve the stabilization device insertion. You say that the enrollee has failed 
conservative approaches to treatment including physical therapy, medications, and injections. You say that you 
recommend this minimally invasive procedure when conservative treatment has failed, and the procedure 
should be approved. The Plan denied your request. The Plan says this procedure is considered 
investigational. 
 
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 stabilization device insertion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that current evidence based medical guideline and peer reviewed literature 
do not fully support the spinal decompression device procedure over the standard lumbar laminectomy. There 
is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
  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 stabilization device insertion have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the stabilization device insertion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) purchased on March 4, 2022, from 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you would like this claim to be overturned, and be 
reimbursed $500.00. The Plan denied your request. The Plan says you obtained the hearing aids through an 
OON provider. The Plan also says there is no record of prior authorization being on file. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you select a device from the list available through the Plan's participating hearing aid 
supplier. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5261) purchased on March 4, 2022, from an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high-frequency chest-wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve an HFCWOD. 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 an HFCWOD have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
 
  The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall 
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve a high-frequency chest-wall oscillation device (HFCWOD).
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 you strongly recommend an LTACH is 
the most appropriate level of care for this enrollee. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate inpatient acute care and is currently unstable for transfer to an LTACH. 
 
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 requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not already available at 
the current facility. Our reviewer found that a transfer to the LTACH is not medically necessary as the enrollee 
is not yet stable for transfer and as it would not be clinically advantageous at this time. Our physician reviewer 
also found that completion of treatment at the current facility is recommended. 
 
 
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive periodontal evaluation (D0180) provided by 
an out-of-network provider on April 6, 2022. 
 
You asked the Plan to pay for comprehensive periodontal evaluation. You say that you were unaware that this 
was not a covered benefit. The Plan denied your request. The Plan says the rendered dental work is not a 
covered benefit. 
 
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 
comprehensive periodontal evaluation (D0180) provided by an out-of-network provider on April 6, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on May 5, 2020. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged.  
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on May 5, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 18 home health physical therapy visits. 
 
You asked the Plan to pre-approve 18 home health physical therapy 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 18 home health physical therapy visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the 
medical records provided there is no documentation that further skilled therapy services are required. After the 
physical therapy treatments already provided, records do not support that the complexity of the enrollee's 
conditions are such that the skills of a professional therapist are required to achieve further improvement in the 
enrollee's symptoms or functional status. Further utilization of the home exercise program appears appropriate 
at this point. Repetitive exercise does not require the expertise of a professional skilled physical therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 18 home health physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 18 home health physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. The Plan denied your request. The Plan says it has been indicated 
that this drug is being dispensed by a pharmacy. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Botox.  
 
Benefits for Botox may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.