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

 
We decided that the Plan does not have to pre-approve a microprocessor knee. 
 
You asked the Plan to pre-approve a microprocessor knee. The Plan denied your request. The Plan says this is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a microprocessor knee. Our reviewer 
says that the requested microprocessor knee is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the physician documentation does not reveal extenuating factors why the 
enrollee is unable to use a mechanical knee and foot. Furthermore, a review of the Linx system indicates it has 
convenience features which are not medically necessary per Medicare criteria, such as a covered and magnetic 
charging point and a programming application. The requested Linx system exceeds the enrollee's medical needs and 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 a microprocessor knee have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a microprocessor knee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
Records do not support that services in the home with home health care or in a long-term care facility on a part 
time basis are not appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4550 billed for date of service January 14, 
2022. 
 
You asked the Plan to pay for procedure code A4550. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code A4550 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4550 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code A4550 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code A4550 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4550 billed for date of service January 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bi-ventricular pacemaker. 
 
You asked the Plan to pre-approve pacemaker. You say that the enrollee is 100% pacemaker dependent which 
is not advisable for a single chamber device. The Plan denied your request. The Plan says the enrollee's ejection 
fracture is 55-60% and the pacemaker is only required 44% of the time. 
 
The Plan follows Medicare rules. Medicare rules state that cardiac pacemakers may be covered under certain 
conditions. 
 
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 pacemaker. Our reviewer says that the 
enrollee does not meet criteria for the requested pacemaker. Our physician reviewer found the enrollee's 
ejection fraction is 55-60% and the pacemaker paces less than 50% of the time. As such, guidelines would not 
endorse the requested upgrade to a bi-ventricular pacemaker. There is insufficient documentation to support the 
medical necessity of this procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pacemaker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a bi-ventricular pacemaker.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on December 3, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says payment cannot be made for the 
services rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the genetic testing services have been 
met. In this case, no medical records were provided to indicate the medical necessity of the services rendered.  Therefore, we decided that the Plan does not have to pay for the genetic testing services provided on December 
3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that this drug is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).  
 Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy provided by a non-contracted provider. 
 
You asked the Plan to pre-approve physical therapy. You say that additional physical therapy is medically 
necessary. The Plan denied your request. The Plan says the medical criteria for PT have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found at this point, the enrollee would benefit from performing her home 
exercise program and she does not require the services of a skilled physical therapist to maintain her strength, 
range of motion and function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve physical therapy provided by a non-contracted provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an office visit provided on July 29, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you feel you should not be 
charged for an office visit during a physical. The Plan denied your request. The Plan says that this cost sharing 
was charged 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 has not been able to obtain medical records from the 
provider in a timely manner. Without this information, we are unable to verify the cost share amount applied to 
office visit. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's 
denial is not substantiated, so we must find in your favor. Therefore, we decided that the Plan has to waive the 
copayment for an office visit provided on July 29, 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 pay for the speech generating device and accessory provided on June 
2, 2021. 
 
You asked the Plan to pay for the speech generating device and accessory. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the claim was submitted untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the speech generating device and accessory was not filed until July 1, 2022. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the speech generating device and accessory 
provided on June 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93321 and 93325 billed for date of service 
August 9, 2022. 
 You asked the Plan to pay for procedure codes 93321 and 93325. You say that these services are supported as 
billed. The Plan denied your request. The Plan says the payment for codes 93321 and 93325 is bundled into 
payment for code 93306. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
93321 and 93325 are both column II codes to column I code 93306. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 93321 and 93325 billed for 
date of service August 9, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal x-ray (74018) provided on April 23, 2022. 
 
You asked the Plan to pay for the x-ray. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible 
for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice 
is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before 
rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 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 the abdominal x-ray (74018) provided on April 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued ongoing diagnostic workup, office visits, 
evaluation and monitoring to be provided by an out-of-network (OON) facility. 
 
You asked the Plan to pre-approve diagnostic workup, office visits, evaluation and monitoring. You say that 
you disagree with the denial. The Plan denied your request. The Plan says except in emergencies, certain 
urgently needed services, out of the area dialysis services, and when the providers in our network cannot 
provide your care, you must use plan providers in order for services to be covered. The Plan also says that there 
are patriating providers with the appropriate training and experience to provide the requested service. 
 
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 
continued ongoing diagnostic workup, office visits, evaluation and monitoring to be provided by an out-of-
network (OON) facility.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for new patient visit. We decided that the Plan does not 
have to waive the copayment for an acupuncture visit.  
 
You asked the Plan to waive the copayment for an acupuncture visit, and new patient visit provided on August 
3, 2022.. You say that the annual notices of change for 2022, under therapeutic services it states you will pay 
50% of the total cost for out of network, not the whole cost. The Plan says that this cost sharing was charged 
correctly. 
 We decided that the Plan has to waive the copayment for new patient visit.  
 
The Plan follows Medicare rules. Medicare rules say that there is a $20 copayment for new patient visits. 
 
The file shows that you have a medical indication for which Medicare will cover this service. Therefore, we 
decided that the Plan has to waive the copayment for new patient visit.  
 
We also decided that the Plan does not have to waive the copayment for an acupuncture visit. 
 
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 $60 
copayment for an acupuncture visit, who is considered an out of network specialist. You are being asked to pay 
$60, rather than the standard $65 copayment. Therefore, we decided that the Plan does not have to waive the 
copayment for an acupuncture visit. 
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the denial of the 
LTACH admission was appropriate given the clinical scenario and the guidance presented. 
 
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 medical record does not indicate that the enrollee requires services that she is not 
currently receiving. The enrollee still requires acute care services before transitioning to a lower 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Volara system. 
 
You asked the Plan to pre-approve the Volara system. You say that the Volara system is medically necessary. 
The Plan denied your request. The Plan says the Volara system 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 the Volara system. Our reviewer says 
that the Volara system is not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the requested Volara system at issue in this case meets all Medicare 
criteria for the enrollee. Provided records do not document that use of the Volara system has been shown in 
controlled studies to result in improvement in long term health outcomes (compared to conventional treatment) 
in patients with asthma, bronchiectasis and tracheobronchomalacia. 
 
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 Volara system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Volara system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint injection. 
 
You asked the Plan to pre-approve a facet joint injection. You say that a facet joint injection is medically 
necessary. The Plan denied your request. The Plan says the requested facet joint injection does not meet the 
Medicare LCD 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 a facet joint injection. Our reviewer 
says that a facet joint injection is not medically necessary. Our physician reviewer found that in this case, the 
enrollee has already had two medial branch blocks (MBBs) with 95% pain relief for five days. There was no 
assessment following the second MBB. It is unclear why a third MBB is being requested when records 
discussed an RFA. There has also not been at least 3 months of pain relief, seemingly, from either MBB. There 
are no notes on whether or not the enrollee could return to activities of daily living compared to baseline. The review has determined that the requested facet joint injections do not meet the Medicare LCD 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 a facet joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a facet joint injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140) and intraoral imaging (D0220) 
provided by a participating provider on September 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 D0140 was exhausted on date of service May 23, 2022, and July 18, 2022, and D0220 
was exhausted on May 23, 2022.. Therefore, we decided that the Plan does not have to pay for an oral 
evaluation (D0140) and intraoral imaging (D0220) provided by a participating provider on September 7, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill. 
 
You asked the Plan to pre-approve the special supplemental benefits for the chronically ill. You say that this 
benefit is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the special supplemental benefits for the chronically ill have not been met. Specifically, no records 
were provided to confirm you have a qualifying condition. Therefore, we decided that the Plan does not have to 
pre-approve special supplemental benefits for the chronically ill.