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

We decided that the Plan does not have to pay for portable X-Ray services provided on November 26, 2022, by an out-of-network (OON) provider.

You asked the Plan to pay for portable X-Ray. You say that the Plan is financially responsible for this service. The Plan denied your request. The Plan says this provider is out-of-network with the Plan and authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for portable X-Ray services provided on November 26, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for remote monitoring services provided on July 26, 2022.
 
You asked the Plan to pay for remote monitoring services. You say that the records attached support the services provided. 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 remote monitoring services in this appeal is not a network provider with the Plan. The Plan did not pre-approve the remote monitoring services at issue. We found no exception that would require the Plan to pay for remote monitoring services. Therefore, we decided that the Plan does not have to pay for remote monitoring services provided on July 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on October 12, 
2022. 
 
You asked the Plan to pay for the pneumatic compression. You say that this device was provided for use during 
the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a procedure 
is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on October 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on October 17, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on October 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography, heart, without contrast 
material, with quantitative evaluation of coronary calcium. 
 
You asked the Plan to pre-approve a computed tomography, heart, without contrast material, with quantitative 
evaluation of coronary calcium. You say that the enrollee needs a Computed tomography, heart, without 
contrast material, with quantitative evaluation of coronary calcium. The Plan denied your request. The Plan 
says preventative and screening services cannot be approved; Medicare does not cover the requested study for 
screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a computed tomography, heart, without 
contrast material, with quantitative evaluation of coronary calcium. Our reviewer says that the service is not 
medically necessary. Our physician reviewer found the medical necessity of a screening test not covered for 
asymptomatic patients has not been established in the records provided. 
 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 computed tomography, heart, without contrast material, with quantitative 
evaluation of coronary calcium have not been met. Therefore, we decided that the Plan does not have to pre-
approve a computed tomography, heart, without contrast material, with quantitative evaluation of coronary 
calcium.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Proteor Rush Rogue 2 prosthetic ankle/foot system 
described by codes L5984 and L5987. 
 
You asked the Plan to pre-approve the requested prosthetic ankle/foot system. You say that it is felt that the 
requested ankle/foot system is required as the enrollee has potential to be a level 3 ambulator. The Plan denied 
your request. The Plan says the documentation does not support the functional level of 3. 
 
The Plan follows Medicare rules. Medicare rules say that ankle/foot systems that are described by code L5987 
are covered only for patients with functional level of 3 or higher. 
 
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 prosthetic ankle/foot 
system. Our reviewer says that the requested ankle/foot system is not medically reasonable and necessary.  Our physician reviewer found the requested ankle/foot exceeds the enrollee's functional needs. The requested 
Proteor Rush Rogue 2 is noted to be waterproof to fresh and salt water and can be suitable for high impact 
activities. The documentation does not reveal that the enrollee's activities require a specialized waterproof foot 
or that this enrollee participates in high impact activities or activities that require a functional level 3 foot. 
Given his comorbidities including hip and knee arthritis and his functional activities, the documentation does 
not support that he requires the Proteor Rush Rogue 2 K3 level foot.  
 
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 prosthetic ankle/foot system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Proteor Rush Rogue 2 prosthetic ankle/foot system 
described by codes L5984 and L5987.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of hyperbaric oxygen therapy. 
 
You asked the Plan to pre-approve continuation of hyperbaric oxygen therapy. You say that continuation of 
hyperbaric oxygen therapy is medically necessary. The Plan denied your request. The Plan says continuation of 
hyperbaric oxygen therapy does not meet the Medicare NCD coverage criteria. 
 
The Plan follows Medicare 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 pre-approve continuation of hyperbaric oxygen 
therapy. Our reviewer says that continuation of hyperbaric oxygen therapy is not considered medically 
necessary in this case. Our physician reviewer found that in this case, the request for continued hyperbaric 
oxygen therapy for a compromised skin graft is not medically necessary because the wound has not 
demonstrated healing within the first 30 days of hyperbaric oxygen therapy treatment and there no longer 
appears to be a compromised skin graft given that eschar has formed. The review has determined that  the 
requested continuation of hyperbaric oxygen therapy does not meet the Medicare NCD coverage criteria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of hyperbaric oxygen therapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continuation of hyperbaric oxygen therapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman (interspinous-interlaminar fusion 
device) (20930, 22612, 22840) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the Minuteman procedure. You say that it is your position that the denial for 
this procedure is unwarranted and unsupported by the enrollee's current medical status and is inconsistent with currently accepted medical practice. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. Medicare does not cover Minuteman procedure at this time. 
 
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 
the Minuteman (interspinous-interlaminar fusion device) (20930, 22612, 22840) 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 the pneumatic compression device provided on October 19, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. 
 The Plan denied your request. The Plan says equipment used in a facility for a procedure is not separately 
payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on October 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair transit kit. 
 
You asked the Plan to pre-approve transit kit. You say that you need this option in order to use your wheelchair 
to attend doctor's appointments. The Plan denied your request. The Plan says this is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a wheelchair transit kit.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that the requested services are 
experimental/investigational for the enrollee's condition. 
 
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 proton beam therapy. Our reviewer says 
that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that chordomas are rare tumors, most often arising from the base of skull or sacral region. 
Given the relative radiation resistance of chordomas, proton beam therapy is often considered medically 
necessary in an effort to maximize dose to the tumor and minimize dose to the cord and other surrounding 
tissues. The primary advantage of proton therapy is the ability to escalate the dose to the target while 
maintaining acceptable dose delivery to the normal critical tissues. Cancer treatment guidelines acknowledge 
that proton beam therapy should be considered and that the doses needed to treat chordomas are high and in 
excess of what the spinal cord and nerve roots are generally accepted to tolerate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have been met. Therefore, we decided that the Plan has to 
pre-approve proton beam therapy.  
 
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 home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee requires home ventilation. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a home ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found that the provided records in this case document a diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease. The 
enrollee's records document that the home ventilator is being requested for use in a pressure support mode and 
average volume assured pressure support (AVAPS) mode with auto-EPAP (AE) which could be provided by a 
bilevel positive airway pressure (BiPAP) device with AVAPS and a back-up rate. Provided records do not 
document trial and failure of a BiPAP device with AVAPS and a back-up rate. Thus, criteria for coverage are 
not 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the osteogenesis stimulator, electrical, non-invasive, 
other than spinal applications (E0747). 
 
You asked the Plan to pre-approve the osteogenesis stimulator. You say that this enrollee had surgical 
intervention for treatment for an established non-union, thus meeting Medicare criteria. The Plan denied your 
request. The Plan says there is no indication for this bone stimulator. The enrollee is approximately 60 days 
after the operation. It is premature to consider nonunion at 60 days. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for 
nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial 
radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment 
with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days. 
 
In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The file does not 
show that there were 2 or more serial radiographs separated by 90 or more days confirming that healing had 
ceased. Therefore, we decided that the Plan does not have to pre-approve the osteogenesis stimulator, electrical, 
non-invasive, other than spinal applications (E0747).
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 the enrollee is stable for transfer and 
clearly exceeds the LTACH criteria for admission. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate in-patient acute care and does not require transfer to a Long-Term Acute Care Hospital. 
 
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 available at the 
current acute care hospital. 
 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 pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you have had teeth removed and can no 
longer use the partial dentures, and you now need a complete set. The Plan denied your request. The Plan says 
your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 3, 2019. Therefore, 
we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve accessories for a positive airway pressure (PAP) device 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve PAP accessories. You say that the items at issue are a necessity for your 
care. The Plan denied your request. The Plan says rules for coverage for OON 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 
accessories for a PAP device to be provided by an OON provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services provided on December 6, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON mental health services. You say that you went to see this OON provider 
after your husband died by suicide. You say that you have a good working relationship with the OON provider 
and she has helped you greatly. The Plan denied your request. The Plan says the services in dispute were from 
an out-of-network provider and there was no prior authorization issued. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the mental health services provided on December 
6, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on October 21, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on October 21, 2022.