Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the SNF care. 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. 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 the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there is no documentation the enrollee 
needs daily skilled services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF care have not been met. Specifically, medically necessary services can 
be obtained in a lower level of care. This means admission into an SNF is not medically necessary. Therefore, 
we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient behavioral health admission. 
 
You asked the Plan to pre-approve inpatient admission. You say that the enrollee requires a high level of 
monitoring. The Plan denied your request. The Plan says the requested continued stay is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 
 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 inpatient admission. Our reviewer says 
that the inpatient behavioral health admission is not medically necessary. Our physician reviewer found the 
records provided for the admission of this enrollee does not meet the criteria for continued acute inpatient 
mental health treatment for the dates in question of May 4, 2022 forward as the enrollee was not shown to be a 
danger to herself or others. The reviewer found that the enrollee was not showing any delusions, auditory or 
visual hallucinations and was cooperative/compliant with treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve inpatient behavioral health admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on December 21, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were not treated 
on December 21, 2021, but were treated on December 17, 2021 due to a toothache you had. You also say that 
there is no way you exceeded the frequency limitation. The Plan denied your request. The Plan says this service 
exceeds the frequency limitation in your benefit plan. 
 
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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on December 17, 2021 and your problem focused limited oral 
evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for 
the problem focused limited oral evaluation (D0140) provided on December 21, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve MRI, spinal canal and contents, lumbar; without contrast material 
(CPT code 72148). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is necessary. The Plan denied your request. 
The Plan says that there is no documentation of a recent six (6) week trial 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 physician reviewer found 
the record indicates that you have low back pain that began approximately one month ago after sudden 
movement. You have previously undergone L2-L3 laminectomy. The record indicates that the pain is 
associated with ipsilateral radiculopathy, and you require two (2) canes instead of one. The requested service is 
medically necessary and reasonable for the diagnosis and treatment for your clinical condition at this time. The 
elements of the coverage criteria are satisfied. The requested service is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have been met. Therefore, we decided that the Plan has to pre-approve 
MRI, spinal canal and contents, lumbar; without contrast material (CPT code 72148).  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the SNF care. 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. 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 the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there is no documentation of daily 
skilled services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF care have not been met. Specifically, medically necessary services can 
be obtained in a lower level of care. This means admission into a SNF is not medically necessary. Therefore, 
we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is necessary. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in volume-assured pressure 
support (VAPS) mode with Auto-EPAP (AE) that could be delivered by bilevel positive airway pressure 
(BiPAP) is not covered. 
 
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 the home ventilator. physician reviewer 
found the record indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary 
disease. The enrollee was hypercarbic and responded to treatment with BiPAP. The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. The plan has indicated such a device is available for coverage consideration. The elements of the coverage criteria are not satisfied. 
The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reimburse you minus your applicable coinsurance for an urgent care visit, 
antibiotic and over the counter medication provided on October 22, 2021. 
 
You asked the Plan to reimburse you for an urgent care visit, antibiotic and over the counter medications. The 
Plan denied your request. The Plan says that antibiotics and over the counter medications are not mentioned as 
part of covered urgent care services. 
 
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 does not say in clear and accurate terms 
how much you should expect to pay for antibiotics and over the counter medications as part of urgently needed 
services.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a 20% 
coinsurance up to $65 for antibiotics and over the counter medications as part of urgently needed services. The 
Plan contract does not clearly say how much enrollees must pay for antibiotics and over the counter 
medications. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. 
Therefore, we decided that the Plan has to reimburse you minus your applicable coinsurance for an urgent care 
visit, antibiotic and over the counter medication provided on October 22, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services provided to the enrollee on August 14, 
2021 and August 15, 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 the place of service is inappropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the outpatient - on campus hospital POS code. However, it is not clear if the enrollee was outpatient in this case. Therefore, we decided 
that the Plan does not have to pay for pathology services provided to the enrollee on August 14, 2021 and 
August 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not support the need for a skilled nurse to make more visits. 
 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that in this case, 
the documentation doesnt support that the enrollee requires additional skilled nursing services  to provide 
treatment that is medically necessary. The enrollee does not require additional skilled nursing services to 
effectively provide treatment, care, and/or services in order to improve the enrollees condition, perform a 
maintenance program to maintain the members condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health skilled nursing services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on December 29, 2021. 
 
You asked the Plan to pay for the prophylaxis. You say that this service was required for follow up after cancer 
treatment. You also say that you had to see the dentist every three months for a year after radiation. The Plan 
denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan. 
 
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, prophylaxis (D1110) is limited to two 
procedures per plan year. The record shows that you received prophylaxes (D1110) on January 14, 2021, and 
April 14, 2021 and your prophylaxis (D1110) benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the prophylaxis (D1110) provided on December 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid circulating cold pump (E0218) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary. 
 
Medicare statutorily does not cover this request. 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 pre-approve a 
fluid circulating cold pump (E0218) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0668, E0656). 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that please refer to the 
previously submitted treatment records where the healthcare team notes 4 weeks of conservative treatments 
failed and documents truncal swelling which completely rules out the use of a simple leg pump. The Plan 
denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema 
pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device 
(E0652) and segmental pneumatic appliance (E0668, E0656).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 20, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says there is no physician 
order. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the genetic testing provided on January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection. 
 
You asked the Plan to pre-approve a repeat epidural steroid injection. You say that this injection is medically 
reasonable. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 
 
 
 
 
 
 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 a repeat epidural steroid injection. 
have been met. Specifically, no documentation was returned from the first epidural injection. Although the 
documentation specifies that there was previous relief from a previous injection, no documentation was 
returned to indicate when this injection was performed. Therefore, we decided that the Plan does not have to 
pre-approve a repeat epidural steroid injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cilostazol. 
 
You asked the Plan to pre-approve Cilostazol. You say that the drug is necessary for the enrollee. The Plan 
denied your request. The Plan says the claim denied correctly. 
 
 
 
 
 
 
 
 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 Cilostazol.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fitting and preparation (A5500) and foot orthotics (L3010) 
provided on October 14, 2021. 
 
You asked the Plan to pay for fitting and preparation and foot orthotics. You say that the items at issue were a 
medical necessity for you. The Plan denied your request. The Plan says these items are not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for fitting and preparation (A5500) and 
foot orthotics (L3010) provided on October 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this was medically necessary. The Plan denied your 
request. The Plan says claim payment for managed care plan members for the covered routine costs associated 
with a clinical trial is the responsibility of the original Medicare contractor, and not the managed care plan. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
 
 
 
 
 
 
 
 In this case, you asked the Plan to pre-approve the drug as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Keytruda for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular genetic testing provided to the enrollee on 
March 9, 2021. 
 
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says Medicare Part B covers cardiovascular disease screening tests when ordered by the 
physician who is treating the beneficiary for the purpose of early detection of cardiovascular disease in 
individuals without apparent signs or symptoms of cardiovascular disease. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the PCP did not order cardiovascular genetic testing. The testing kit was received via mail, collected 
specimen by buccal swab, and forwarded back to lab via mail. The PCP felt that this test was not needed. The 
review has determined that the services at issue in this case were 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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for cardiovascular genetic testing provided to the enrollee on March 9, 2021.