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

 
We decided that the Plan does not have to pay for the power mobility scooter you purchased on November 6, 
2021. 
 
You asked the Plan to pay for the power mobility scooter. You say that other providers did not have the item 
you wanted. The Plan denied your request. The Plan says because you purchased this scooter from a provider 
that does not participate in Medicare, this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items or services to be covered by Medicare, the 
provider or supplier must be enrolled in the Medicare program.  The provider from whom you purchased the 
scooter in question is not enrolled in the Medicare program. 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the power mobility scooter have not been met. Therefore, we decided that the Plan does not have to 
pay for the power mobility scooter you purchased on November 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0482) provided on February 10, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the healthplan requires utilization of 
network providers when possible and available, and requires authorization for certain 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 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 drug testing services (G0482) provided on 
February 10, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. The Plan denied your request. The Plan says the 
requested injection is not supported as part of a series (one right after the other). The response to a prior 
injection should be evaluated before having another one. 
 
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 epidural steroid injections. Our 
reviewer says that the requested epidural steroid injection is not medically necessary. Our physician reviewer 
found that according to the coverage criteria, the requested repeat service is supported for either of the 
following: 1) enrollee's pain or function was improved by at least 50% for three months after the last injection, 
or 2) the first injection did not help the enrollee's pain, but the doctor will use a different approach or 
medication for the next one, and it has been at least 14 days since the first injection. The records submitted do 
not show either of these. The repeat injection is proposed several weeks less than the required 3 month interval 
and the record provides no evidence of radicular pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three surgical placements of implant bodies: endosteal 
implants (D6010 x3) provided on November 18, 2021. 
 
You asked the Plan to pay for the endosteal implants. You say that you understand that you are entitled to 
reimbursement for these services. The Plan denied your request. The Plan says these services are not covered 
by your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the implant benefit covers only the 
dental implant to hold a complete denture. The provided documentation does not show that these implants were 
provided to hold a complete denture. Therefore, we decided that the Plan does not have to pay for the three 
surgical placements of implant bodies: endosteal implants (D6010 x3) provided on November 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair accessory, electronic connection 
(E2311) power wheelchair accessory, expandable Controller (E2377) and power wheelchair accessory, 
expandable Controller Harness (E2313). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says the available medical 
records do not support necessity of the upgraded electronics. 
 
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 upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no documentation that meets the 
requirements listed in the Local Coverage Article for Medicare coverage for the requested upgraded 
electronics. Provided records document that the enrollee has 3-/5 left upper extremity strength and is 
independent with feeding and hydration thus indicating she has adequate upper extremity strength and function 
to operate the wheelchair's power options with their own switches. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve power wheelchair accessory, electronic connection (E2311) power wheelchair 
accessory, expandable Controller (E2377) and power wheelchair accessory, expandable Controller Harness 
(E2313).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the inhalation of nitrous oxide/analgesia (D9230) provided 
on September 16, 2021. 
 
You asked the Plan to pay for the inhalation of nitrous oxide/analgesia. You say that you would like to know 
why the Plan will not cover the anesthesia for your tooth extraction. The Plan denied your request. The Plan 
says this service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, your dental benefit covers two 
cleanings (regular or periodontal maintenance cleanings). Therefore, we decided that the Plan does not have to 
pay for the inhalation of nitrous oxide/analgesia (D9230) provided on September 16, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you cannot be left alone. The Plan denied your 
request. The Plan says that you do not require an intensive multidisciplinary approach to daily therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found 
that you have with type 2 diabetes, hypertension, and chronic obstructive pulmonary disease (COPD). You 
were admitted to the acute hospital after worsening back pain and leg radiculopathy. Your blood sugars were 
out of control. You underwent spinal decompression surgery. Currently you are improving, but are not able to 
function independently. You have significant difficulties with leg weakness, coordination, and gait dysfunction.  
Importantly, you are described as highly motivated and are able to participate in rehab for at least 3 hours daily.  
Your comorbidities of poorly controlled diabetes and COPD make the inpatient rehab setting most appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee would benefit from a short SNF 
stay in order to improve strength and endurance, as well as to safely ascend and descend the 36 steps at his 
condo. The Plan denied your request. The Plan says the enrollee does not have daily skilled service needs that 
can only be provided on an inpatient basis in a SNF. The Plan says that the enrollee's needs can be met at an 
alternate level of care.  
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there is no documentation that the 
enrollee requires skilled nursing services. The records do not document the need for intravenous medications, 
new tube feeding, or ostomy care or daily complex wound care. The documentation does demonstrate a need 
for skilled therapy services, but they are not required on a daily basis. The enrollee is walking household 
distances with a rolling walker with stand-by assistance and is stand-by assist for transfers. The provided 
records do not document a significant decline in the enrollees functional status to necessitate daily inpatient 
skilled therapy services. There is no documentation that the enrollee requires the services on an inpatient basis, 
only in a skilled nursing facility setting. Services in the home with home health care or in a long-term care 
facility on a part time basis appear 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Donepezil. 
 
You asked the Plan to pre-approve Donepezil. You say that she is doing well and has remained stable. The Plan 
denied your request. The Plan says Donepezil to be administered at home is not covered under the Part B 
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 Donepezil.  
 
 Benefits for Donepezil 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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the two crowns (D2740 x2) provided on December 6, 2021. 
 
You asked the Plan to pay for the crowns. You say that you were not aware that these services would not be 
covered. The Plan denied your request. The Plan says that crowns are not covered under your benefit plan. 
 
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 Independent Review Entity (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. The Plan did not provide a copy of the applicable 2021 Evidence of Coverage 
for this case. Without this information we cannot determine that the Plan's coverage rules support the denial of 
payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. 
Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that 
the Plan has to pay for the two crowns (D2740 x2) provided on December 6, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the segmental gradient pressure pneumatic appliance, half 
leg (E0673) and non-segmental pneumatic appliance for use with pneumatic compressor, half arm (E0655). 

You asked the Plan to pay for the pneumatic appliances. You say that due to the enrollee's health conditions, 
the doctor believed she would benefit from the VCU system to improve swelling and venous outflow. The Plan 
denied your request. The Plan says the documentation does not support that the services rendered were 
medically necessary. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 pneumatic appliances. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no documentation that the segmental 
gradient pressure pneumatic appliance, half leg (E0673) and non-segmental pneumatic appliance for use with 
pneumatic compressor, half arm (E0655) meet Medicare criteria for medically necessary for the enrollee in this 
case. The provided records do not document the enrollee has lymphedema on any examination. Provided 
records do not document the enrollee has lymphedema on any examination. 
 
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 pneumatic appliances have not been met. Therefore, we decided that the 
Plan does not have to pay for the segmental gradient pressure pneumatic appliance, half leg (E0673) and non-
segmental pneumatic appliance for use with pneumatic compressor, half arm (E0655).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the patient was admitted for myxedema coma. Medical problems are stable. There are 
no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. In conclusion, there is not a reasonable expectation that this patient will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the PT visits. You say that this is a referral by your doctor because you are 
recovering from surgery. You also say that you contest that there has been progress towards the goal, contrary 
to what the Plan states on the denial. The Plan denied your request. The Plan says that no PT records, 
treatments, and goals have been provided, with the last records for PT visits being from November of 2021. 
The Plan also says that more recent records are needed to provided medical reasons why more home PT is 
needed. 
 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 PT visits. Our reviewer says that the 
requested, ongoing, home health PT service is not medically necessary or reasonable. Our physician reviewer 
found you do not have documented skilled therapy needs. 
 
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 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 6 physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-rays (D0220 x 3), post and core in addition 
to a crown (D2954), unspecified preventive services (D1999 x 3), root canal (D3310), cone beam CT (D0367), 
and extraction (D7140) provided from August 31, 2020, to October 6, 2020. 
 
You asked the Plan to pay for the dental services. You say that you had a serious medical problem diagnosed. 
You also say that you should be reimbursed for these services. The Plan denied your request. The Plan says the 
services you received were purely dental in nature. The Plan says that the services you received are not eligible 
for coverage under your medical benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the periapical x-rays (D0220 x 
3), post and core in addition to a crown (D2954), unspecified preventive services (D1999 x 3), root canal 
(D3310), cone beam CT (D0367), and extraction (D7140) provided from August 31, 2020, to October 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab service provided on September 27, 2021. 
 
You asked the Plan to pay for the lab service. You say that drug testing is needed to monitor possible opioid 
abuse. The Plan denied your request. The Plan says this code is not separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 83789 is mass spectrometry and tandem mass 
spectrometry (e.g., MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. We find that CPT code 83789 is not supported. Validity testing on 
urine specimens used for drug testing shall not be separately billed. Based on this information, we decided that 
Medicare rules for coverage of the lab service have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab service provided on September 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from August 20, 2020, 
through August 27, 2020. 
 
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider did not submit medical records. 
 
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 inpatient hospital care provided from 
August 20, 2020, through August 27, 2020. have been met. The provider did not submit medical records. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided from August 20, 
2020, through August 27, 2020.