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

 
We decided that the Plan does not have to pay for anesthesia services provided on January 17, 2022. 
 
You asked the Plan to pay for anesthesia services. The Plan denied your request. The Plan says despite multiple 
outreaches by the Plan, this provider has not submitted any clinical records to support medical necessity of the 
services. 
 
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 anesthesia services provided on January 17, 2022 have been met. No medical records were provided. Therefore, we decided that the Plan does 
not have to pay for anesthesia services provided on January 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed and foam rubber mattress. 
 
You asked the Plan to pre-approve these services. You say that this is the only bed that allows you to transfer 
safely to and from your wheelchair. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Given that the total electric hospital bed is not covered, the requested mattress is also 
not covered. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed and 
foam rubber mattress.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not meant for use in the home. 
 
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 power operated vehicle.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spravato. 
 
You asked the Plan to pre-approve Spravato. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 Spravato.  
 
Benefits for Spravato 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is a medically necessary 
treatment. The Plan denied your request. The Plan says this remains experimental. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed. 
 
 
 
 
 
 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laparoscopic cholecystectomy, gallbladder surgery 
(47562) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the surgical procedure. You say that you do not want to see any other doctor 
since this has been your treating doctor since the beginning when you went to the emergency room. The Plan 
denied your request. The Plan says enrollees must receive their medical services from an in-network provider 
with the exception being urgent or emergent services. Non-emergent services with non-contracted providers 
require prior authorization before services being rendered. 
 
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 laparoscopic cholecystectomy, gallbladder surgery (47562) to be provided by an out-of-network (OON) 
provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says medical necessity rules for SNF care have not been 
met. 
 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 medically reasonable and necessary in this case. Our physician reviewer found that 
the enrollee has no identifiable skilled nursing service needs. The enrollee does have identifiable skilled 
therapy service needs. However, the enrollee does not require skilled nursing or therapy services on a daily 
basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided to the enrollee on 
December 2, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says code 99285 is not supported. 
 
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, the CPT Code Manual definition of code 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee was a then 37-year-
old woman with a medical history of Crohn's disease, diabetes, and hypertension, who presented to the Emergency Department with mild vomiting and abdominal cramping. The enrollee was in no acute distress. 
The abdominal exam was unremarkable, with normal bowel sounds, and no distension, tenderness, or guarding. 
Laboratory tests were ordered. IV sodium chloride, ondansetron, and famotidine were administered. The 
enrollee was diagnosed with gastritis, with secondary impressions of impetigo and vomiting. Prescriptions 
included doxycycline, mupirocin and ondansetron. The clinical documentation does not support decision 
making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room services provided to the enrollee on December 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging (78452). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of this 
service. 
 
The Plan follows Medicare rules. Medicare rules say that indications for myocardial perfusion imaging is acute 
myocardial infarction, unstable angina, chronic ischemic heart disease, congenital heart disease, and post-
transplant cardiac disease. 
 
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 this service. Our reviewer says that this 
service is not medically necessary. Our physician reviewer found that at issue is the medical appropriateness 
and necessity of carrying out a radionuclide stress test. The enrollee has a history of shortness of breath and 
edema. The enrollees pre-test probability for an abnormal test is low and there is no documentation that the 
electrocardiogram shows an uninterpretable pattern.  There is no evidence provided that would support the need for radionuclide stress testing. In summary, there is 
insufficient documentation to support the medical necessity for the requested cardiac stress testing in this 
enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve myocardial perfusion imaging (78452).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional massage therapy visits (97124). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your request exceeds the allowable benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. However, 
the Plan provides a supplemental benefit for massage therapy. Therefore, the Plans rules apply in this case.  
 
We have reviewed the case file and the Plans rules. Based on this information, we decided that the Plans rules 
for coverage of the requested services have not been met. Specifically, the Plan covers up to ten massage 
therapy visits per year, additional visits are not covered. The Plan has previously authorized ten massage 
therapy visits for you starting March 29, 2022, through March 29, 2023.  Therefore, this benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve 
additional massage therapy visits (97124).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantable neurostimulator. 
 
You asked the Plan to pre-approve implantable neurostimulator. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that PENS is only covered for certain indications. 
 
 We looked at the file and Medicare rules. Review of the file shows that the requested device is not an 
implantable neurostimulator requiring surgical implantation into the central nervous system or targeted 
peripheral nerve and is not implanted via a procedure performed in an operating room. This device is an 
electroacupuncture device placed behind the ear. Therefore, the requested service is not a covered benefit. 
Based on this information, we decided that Medicare rules for coverage of implantable neurostimulator have 
not been met. Therefore, we decided that the Plan does not have to pre-approve implantable neurostimulator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a Coflex spinal device. 
 
You asked the Plan to pre-approve the Coflex procedure. You say that this is a medically necessary treatment. 
The Plan denied your request. The Plan says the rules are not met for this procedure. 
 
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 Coflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Coflex device is experimental. More research is needed. 
 
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 Coflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a Coflex spinal device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement ultralightweight manual wheelchair. 
 
You asked the Plan to pre-approve these services. You say that you are having issues with your current 
wheelchair. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement durable medical equipment is 
covered in the case of irreparable damage or when the equipment as exceeded the reasonable lifetime period of 
five years.  
 
 
 
 
 
 We looked at the file and Medicare rules. The file shows that your current wheelchair is not more than five 
years old. The Plan has approved an evaluation to determine if your chair can be repaired before proceeding to 
evaluate for a new wheelchair. At this time, a replacement chair is not covered. Therefore, we decided that the 
Plan does not have to pre-approve a replacement ultralightweight manual wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested item. You say that the sensors do not stay on for the full 14 
days. The Plan denied your request. The Plan says your current device is not malfunctioning. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a continuous glucose monitor. The file does not show that your current device is 
of irreparable damage. Your current device serves the same purpose as the requested item. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the non-preferred diabetic supply, Accu-click Fastclix 
lancets. 
 
You asked the Plan to pre-approve the non-preferred diabetic supply. You say that you have been prescribed 
this brand The Plan denied your request. The Plan says the requested item is not on the Plan's list of preferred 
diabetic supplies. 
 
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. There is no documentation that the enrollee has tried and failed the 
Plan preferred Abbot product or LifeScan product.  Based on this information, we decided that Medicare rules 
for coverage of the non-preferred diabetic supply have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the non-preferred diabetic supply, Accu-click Fastclix lancets.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Orthovisc. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has chronic bilateral shoulder pain due to osteoarthritis. The enrollee has failed medical 
therapy and physical therapy. The enrollee had hyaluronan injections of the shoulders in 2019, which were 
beneficial. The documentation does not support that the enrollee has tried and failed Euflexxa, SupartzFX, 
Durolane, and Gel-SYN-3. The documentation does not support that Euflexxa, SupartzFX, Durolane, or Gel-
SYN-3 would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee 
does not meet step therapy 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 Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve an office visit to be provided by the requested out-of-network provider. The 
Plan denied your request. The Plan says the enrollee must receive care from a network provider. In most cases, 
care received from an out-of-network provider will not be 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 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 Plan says the 
enrollees needs can be met by Plan contracted 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence wipes. 
 
You asked the Plan to pre-approve incontinence wipes. You say that you don't think the member's doctor would 
have prescribed these wipes if they were not medically needed. The Plan denied your request. The Plan says 
these items are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence wipes may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence wipes.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a percutaneous electrical nerve stimulator 
(PENS). 
 
You asked the Plan to pre-approve the PENS placement. You say that the requested neurostimulator will 
eliminate/decrease localized and referred pain. muscle spasm relaxation, improve clinical picture, significant 
increase mobility without pain and adjunctive treatment in the management of post-traumatic acute pain. The 
Plan denied your request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
The Plan follows Medicare rules. Medicare rules say that PENS may be considered reasonable and necessary 
for certain types of pain.  
 
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 PENS placement. Our reviewer says 
that the requested PENS unit is not medically necessary. Our physician reviewer found use of a PENS unit for 
chronic hip and knee pain therapy is experimental. More research is needed. 
 
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 PENS placement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a percutaneous electrical nerve stimulator (PENS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump. 
 
You asked the Plan to pre-approve a fluid circulating cold pad with pump. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump is not 
covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a fluid circulating cold pad with pump.