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

 
We decided that the Plan does not have to pre-approve a second opinion specialist visit to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a second opinion specialist visit. You say that you would like a referral to an 
out-of-network provider because in-network providers have been unable to help you. The Plan denied your 
request. The Plan says the service can be provided by an in-network provider. 
 
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 second opinion specialist visit to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 25, 2022 to 
March 26, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says the claim has not been billed with the 
correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 25, 2022 to 
March 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve uterine fibroid radiofrequency ablation with the Sonata 
System (0404T). 
 
You asked the Plan to pre-approve uterine fibroid radiofrequency ablation with the Sonata System. You say 
that the service is medically necessary. The Plan denied your request. The Plan says there are not enough 
studies on Sonata radiofrequency ablation of uterine fibroids to show it is safe and effective. 
 
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 uterine fibroid radiofrequency ablation 
with the Sonata System. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is insufficient literature to support 
the safety and efficacy, as defined by Medicare rules, of the requested procedure for the enrollee's 
condition. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of uterine fibroid radiofrequency ablation with the Sonata System have not been 
met. Therefore, we decided that the Plan does not have to pre-approve uterine fibroid radiofrequency ablation 
with the Sonata System (0404T).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 27, 2022, to 
February 25, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have supplied the required 
NOA. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 27, 2022, to 
February 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intermittent limb compression device. 
 
You asked the Plan to pre-approve intermittent limb compression device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 intermittent limb compression device. 
Our reviewer says that the item is not medically necessary. Our physician reviewer found the member does not 
have lymphedema or chronic venous insufficiency with venous stasis ulcers. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intermittent limb compression device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve intermittent limb compression device.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dermabrasion, segmental, face (15781) provided 
December 17, 2021. 
 
You asked the Plan to pay for the surgical procedure. You say that please find the attached medical records and 
process the claim for payment. The Plan denied your request. The Plan says This procedure is considered a 
cosmetic procedure for the diagnosis (C44.311 - Basal cell carcinoma of skin of nose). 
 The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 pay for the surgical procedure. Our reviewer says 
that the records do not support that this service is medically necessary. Our reviewer found in this case the 
record indicates that the enrollee has Basal cell carcinoma of skin of nose. The local coverage determination 
enumerates the conditions and limitations under which coverage is available for the requested service. The 
noted condition is not one for which coverage is available under the local coverage determination. The 
elements of the coverage criteria are not satisfied, and the requested service is not 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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pay for the dermabrasion, segmental, face (15781) provided December 17, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 18, 2022, to 
April 16, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the claim was denied incorrectly. 
The Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 18, 2022, to April 
16, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing provided on August 10, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says that the testing is excluded from coverage. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the testing services by a contract provider. The file does not show that the plan 
provided notice that the testing services would not be covered. Under Medicare rules, this means the testing 
services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the genetic 
testing provided on August 10, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are in need of inpatient rehabilitation to be able 
to get back home. The Plan denied your request. The Plan says the IRF services you requested do not meet the 
requirements for approval. 
 
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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 
 Our physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve infusion therapy, Monovisc Inj 88mg (J7327). 
 
You asked the Plan to pre-approve infusion therapy. You say that you disagree with the denial. The Plan denied 
your request. The Plan says This medication is given by injection directly into the knee. The requested 
medication can only be approved every six months. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare rules say that repeat series of hyaluronan knee injection(s) 
for patients who have responded to a prior series is considered to be reasonable and necessary when symptoms 
have recurred, at least six months have elapsed since the prior series of injections and there was significant 
improvement in pain and functional capacity achieved with the prior series of injections using a standardized 
assessment tool. The records show your last injection was on November 16, 2022, therefore, you do not meet 
Medicare criteria for a repeat injection earlier than six months. Based on this information, we decided that 
Medicare rules for coverage of infusion therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve infusion therapy, Monovisc Inj 88mg (J7327).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wrist injection provided on August 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the wrist injection. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says unauthorized, out-of-network care is not covered. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 pay for the wrist injection. Our reviewer says that the records do not indicate that the 
care provided was medically necessary. Our physician reviewer found the enrollee did not have any signs of 
needing emergency care such as infection, fracture, allergic reaction or otherwise. It would have been 
medically reasonable to delay the services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the wrist injection have not been met.  
 
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 pay for the wrist injection. Therefore, we decided that the Plan does 
not have to pay for a wrist injection provided on August 31, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport provided on March 19, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the medical records provided support the need for the ambulance transport. The Plan denied your request. The 
Plan says the ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 pay for the ambulance service, basic life support, 
non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary.  
 Our physician reviewer found the transportation via ambulance from the emergency department to the 
enrollee's residential facility was not medically necessary. The enrollee did not require the expertise of trained 
personnel or the equipment available only on an ambulance in order to effectuate a safe transport. 
Transportation could have been provided by other means (stretcher van, wheelchair van) without endangering 
the enrollee's 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 the ambulance service, basic life support, non-emergency transport have not 
been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life 
support, non-emergency transport provided on March 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652), a segmental 
pneumatic appliance for use with pneumatic compressor, trunk (E0656) and a segmental pneumatic appliance 
for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you have 
extreme lymphedema that needs to be treated as it is the worst case possible. You could end up losing life 
without treatment. The Plan denied your request. The Plan says your request is not medically necessary 
because your records show you do not have at least four weeks of regular, daily, multiple-hour home usage of 
the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in 
and who regularly and successfully uses the appliance provided. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the 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 PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652), a segmental pneumatic appliance for use with pneumatic compressor, trunk (E0656) and a segmental 
pneumatic appliance for use with pneumatic compressor, full leg (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595), provided on 
September 1, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the medical records do not indicate these items are necessary. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies 
(A4595), provided on September 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE) (93306). 
 
You asked the Plan to pre-approve a TTE. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the service 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 a TTE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found clinical guidelines do not support carrying out a TTE in this setting. In summary, there is no 
supportive evidence for the medical necessity of a TTE in this 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 a TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transthoracic echocardiogram (TTE) (93306).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that in their current condition, the enrollee 
cannot be adequately cared for at a skilled nursing facility and is stable and suitable for transfer to the LTACH. 
The Plan denied your request. The Plan says an LTACH admission is not medically necessary. 
 
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 that the recent notes describe the enrollee as still requiring high flow oxygen support, 
but the enrollee is otherwise hemodynamically stable. The enrollee appears to be improving but still somewhat 
unstable and should only require short-term additional acute care services that can safely be provided at the 
current facility until more stable and appropriate for a lower level of care. There are no services at the LTACH 
that the enrollee requires that are not already available and covered at the current facility.  Our reviewer found 
that transfer to the LTACH is not medically necessary as it would not be clinically advantageous. 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 LTACH services.