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

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and sleeve 
(E0673), provided on August 1, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says this item was not used in a home setting. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the pneumatic compression device was used in an ambulatory surgical center. Therefore, we 
decided that the Plan does not have to pay for the pneumatic compression device (E0675) and sleeve (E0673), 
provided on August 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve recliner lift chair (E0627, E1399). 
 
You asked the Plan to pre-approve recliner lift chair. You say that it is necessary for you to have the requested 
chair and lift because it is a medical reclining chair that can lay flat and help you sleep and not get caught in the 
railings. The Plan denied your request. The Plan says this item is not treating a medical condition. This is a 
convenience item and may be used by individuals for non-medical purposes. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve recliner lift chair (E0627, E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization (93458). 
 
You asked the Plan to pre-approve cardiac catheterization. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request 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 cardiac catheterization. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee had a negative radionuclide stress test. The available documentation 
does not provide the rationale for the requested invasive imaging study. Guidelines do not support a need for 
cardiac catheterization in the enrollee's clinical setting. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization (93458).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit provided on 
October 30, 2022. 
 
You asked the Plan to waive the copayment for the emergency room (ER) visit. You say that you were in the 
waiting room for hours without seeing the doctor. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room (ER) visit. This item/service falls within 
the emergency care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room 
(ER) visit provided on October 30, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the foot and of the ankle. 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied 
your request. The Plan says that the enrollee has not completed 6 weeks of provider directed treatment. 
 
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 
MRI of the foot and ankle is medically necessary. Our physician reviewer found that it is well established that 
this enrollee is suffering with a painful right ankle which has not responded to strappings, boot, ice, heat, and 
medication. Treatment appears to have been initiated on December 31, 2022. Right ankle x-ray dated 
December 31, 2022, does not demonstrate fractures to the right foot or ankle. An MRI has been recommended 
to evaluate the peroneal tendons and the associated painful lateral ankle ligaments. This appears to be a 
reasonable request, noting that the enrollee has not responded to conservative care initiated greater than 4 
weeks ago. Medicare guidelines advise that Medicare will cover services that are reasonable and necessary for 
a diagnosis to be made. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
a magnetic resonance imaging (MRI) of the foot and of the ankle.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a transvaginal ultrasound provided on 
September 21, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you have never had to pay for an 
ultrasound. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for diagnostic radiology services, including an ultrasound provided in a physician's office or 
freestanding facility.  
 
You have been asked to pay a $50 copayment for an ultrasound. This item/service falls within the outpatient 
diagnostic testing and services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a 
transvaginal ultrasound provided on September 21, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on August 24, 2022. 
 
You asked the Plan to pay for physical therapy. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says that 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical therapy 
provided on August 24, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network emergency room (ER) visit 
provided on September 06, 2022. 
 
You asked the Plan to waive the copayment for an in-network emergency room (ER) visit. You say that you 
were sent to the ER due to an infection that you got from a procedure at that facility. They should pay. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for emergency care. 
 
You have been asked to pay a $50 copayment for an in-network emergency room (ER) visit. This item/service 
falls within the emergency care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an in-network emergency room (ER) visit provided on September 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve consultation and testing to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve specialist services. You say that this provider specializes in the treatment 
you need. The Plan denied your request. The Plan says this provider is out-of-network with the Plan and you 
can be treated within the Plan network. 
 
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 
consultation and testing to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and sleeve 
(E0673), provided on August 31, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and sleeve. You say that the items were 
medically necessary. The Plan denied your request. The Plan says this item was used in am ambulatory surgical 
center. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a pneumatic compression device and sleeve was used in an ambulatory surgical center. 
Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and 
sleeve (E0673), provided on August 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital bed (E0261). 
 
You asked the Plan to pay for the hospital bed. You say that the item was medically necessary. The Plan denied 
your request. The Plan says the rental cap limit has been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for these items of durable medical equipment 
(DME), A/B MACs (HHH) and DME MACs pay the fee schedule amounts on a monthly rental basis not to 
exceed a period of continuous use of 15 months. In the tenth month of rental, the beneficiary is given a 
purchase option (see 30.5.2). If the purchase option is exercised, A/B MACs (HHH) and DME MACs 
continue to pay rental fees not to exceed a period of continuous use of 13 months and ownership of the 
equipment passes to the beneficiary. If the purchase option is not exercised, A/B MACs (HHH) and DME 
MACs continue to pay rental fees until the 15 month cap is reached and ownership of the equipment remains 
with the supplier.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the hospital bed have not been met. Therefore, we decided that the Plan does not have to pay for 
the hospital bed (E0261).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98941) provided 
from July 26, 2022, through August 31, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services provided were not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 these services. Our reviewer says that you do 
not meet criteria for coverage of the services provided. Our physician reviewer found that in this case, the 
record indicates that you have a subluxation of the thoracic and lumbar spine. The record provided does not 
document that further clinical improvement can be reasonably expected from ongoing care. The elements of the 
coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the chiropractic manipulative treatments (98941) provided from July 26, 2022, through  
August 31, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve HBO therapy. 
 
You asked the Plan to pre-approve HBO therapy. You say that the requested services are a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the request 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 HBO therapy. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has diagnosed bladder cancer with anemia, hematuria, status post blood 
transfusion, nephrostomy, and bladder irrigation status post radiation therapy. None of the enrollee's conditions 
are covered indications for HBO therapy, and anemia is a non-covered 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 HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve HBO therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation (RFA) (64454). 
 
You asked the Plan to pre-approve genicular RFA. You say that there are multiple studies that have 
demonstrated genicular nerve blocks work well for people experiencing 
consistent pain following a knee reconstruction. You say that the enrollee has a history of a total knee 
replacement that is not causing pain. The Plan denied your request. The Plan says the requested 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 genicular RFA. Our reviewer says that 
the requested genicular RFA is not considered medically reasonable and necessary in this case. Our physician 
reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered 
investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to 
any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee 
replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery. Therefore, the reviewer found that the requested genicular nerve radiofrequency ablation is not medically reasonable or 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 genicular RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular radiofrequency ablation (RFA) (64454).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient hospital services provided by an out-of-network (OON) 
provider on March 4, 2021. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you never received a bill and were 
never told the services were out-of-network. The Plan denied your request. The Plan says that the rendering 
provider was an OON provider and there was no approved authorization on file. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan must cover medically necessary services 
received from non-contracted providers without prior authorization when an enrollee is on a PPO Plan.  
 
We looked at the file and Medicare rules. The Plan has not substantiated their denial reason of prior 
authorization being required because the provider was OON. The enrollee is on a PPO Plan and there cannot be 
prior authorization requirements for non-contracted providers. Based on this information, we decided that 
Medicare rules for coverage of the outpatient hospital services have been met. Therefore, we decided that the 
Plan has to pay for the outpatient hospital services provided by an out-of-network (OON) provider on March 4, 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve an implantable loop recorder. 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 an implantable loop recorder. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is no documentation provided to suggest a history of unexplained syncope, 
cryptogenic stroke or any other apparent indication for an ILR.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder (ILR).
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. The Plan denied your request. The Plan says the enrollee's 
condition requires further care in the acute hospital. 
 
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 the enrollee had surgery for a diverticular abscess. The enrollee is at standby assist for transfers and 
ambulation. The enrollee's functional status does not require intensive rehabilitation. He is functioning at a 
community level. The enrollee's medical condition was not stable for discharge from the acute hospital. The 
requested IRF is not a medical step-down unit for a continued hospital stay. Therefore, the requested services 
are 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on August 12, 2022. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says that 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
August 12, 2022.