Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) (78815). 
 
You asked the Plan to pre-approve PET scan. You say that the enrollee had an abnormal CT scan. You say that 
the enrollee is at a high risk for cancer. You also say that the service is medically necessary. The Plan denied 
your request. The Plan says that the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve PET scan. Our reviewer says that the 
requested PET scan is medically necessary. Our physician reviewer found the provided documentation 
indicates that the enrollee has a high risk for cancer. The reviewer found that since cancer is strongly suspected, 
the requested PET scan is medically reasonable and 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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve positron emission tomography (PET) with concurrently acquired computed tomography (CT) (78815).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing visits in your home (G0299, G0300 x 
36). 
 You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 home health services. Our reviewer 
says that the requested home health services are not medically necessary. Our physician reviewer found the 
documentation does not 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 their condition, perform a maintenance 
program to maintain their condition and/or prevent deterioration. The enrollee has been medically stable 
without any recent exacerbations of chronic medical problems or hospitalizations. Therefore, the reviewer 
found that 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skilled nursing visits in your home (G0299, G0300 x 36).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the ventilator is to be used for the 
treatment of COPD. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you were recently hospitalized with 
acute respiratory failure with hypoxia and delirium, due in part to congestive heart failure. There is a diagnosis 
of COPD, but no pulmonary function tests for confirmation. There are no diagnoses of thoracic restrictive 
disease or neuromuscular disease. There is no documentation of chronic CO2 retention on ABG done while 
stable. If you do have chronic CO2 retention, you may benefit from bipap during sleep, which can provide the AVAPS 
mode. Medicare does not cover a home ventilator when used as bipap. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the next generation sequence (NGS) testing panel provided 
on October 15, 2021. 
 
You asked the Plan to pay for the NGS testing panel. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that panels of tests that include the FANCC gene are 
not covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the NGS testing included testing for the 
FANCC gene. This means the entire panel is not covered. Based on this information, we decided that Medicare 
rules for coverage of the NGS testing panel have not been met. Therefore, we decided that the Plan does not 
have to pay for the next generation sequence (NGS) testing panel provided on October 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on November 26, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 provided on November 26, 2021 
by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan of extracranial arteries (93880) provided on 
January 19, 2022. 
 
You asked the Plan to pay for the duplex scan of extracranial arteries. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says medical records that 
support payment for the services in question were not provided. 
 
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 duplex scan of extracranial arteries 
(93880) provided on January 19, 2022, have been met. In this case, the Plan sent several requests for medical 
records to corroborate the services that were billed. Despite these multiple outreach attempts, no records 
documenting the services were provided. Without these records, we cannot determine if the Medicare criteria for coverage were satisfied in this case. Therefore, we decided that the Plan does not have to pay for the duplex 
scan of extracranial arteries (93880) provided on January 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the requested device is 
medically necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a portable oxygen concentrator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found you have COPD with 
hypoxemia during exercise and were provided with portable tanks. You state tanks are too heavy to manage. 
Medicare requires ambulatory oximetry demonstrating that SpO2 can be maintained at least 91% while on O2 
1-4 L/min using an oxygen conserving device. The medical records do not demonstrate this. 
 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 portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99213) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you have breast cancer, and your doctor is 
recommending you see this surgeon. The Plan denied your request. The Plan says you must use network 
providers to get medical care and services. The Plan also says there in-network providers available. 
 
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 
an office visit (99213) to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hyperbaric oxygen therapy (G0277, 99183). 
 
You asked the Plan to pay for hyperbaric oxygen therapy. You say that the enrollee is at risk of permanent 
deafness in the affected ear if the condition is not aggressively treated. The Plan denied your request. The Plan 
says idiopathic sudden sensorineural hearing loss is a not a covered condition for hyperbaric oxygen treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that hyperbaric oxygen therapy is only covered for 
the conditions listed in the rules section.  
 
We looked at the file and Medicare rules. In this case hyperbaric oxygen is being prescribed to treat idiopathic 
sudden sensorineural hearing loss. This is not one of the covered conditions for this service. Based on this 
information, we decided that Medicare rules for coverage of hyperbaric oxygen therapy have not been met. 
Therefore, we decided that the Plan does not have to pay for hyperbaric oxygen therapy (G0277, 99183).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lenses provided on January 6, 2022. 
 
You asked the Plan to pay for contact lenses You say that your contacts are medically necessary because your 
vision is blurred without them. You say that the denial should be reconsidered, and payment authorized. The 
Plan denied your request. The Plan says one pair of eyeglasses or contact lenses are only covered after cataract 
surgery. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan only covers contact lenses after cataract surgery. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of contact lenses have not been met. Specifically, the contact lenses were not purchased after cataract 
surgery. Therefore, we decided that the Plan does not have to pay for contact lenses provided on January 6, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit received on February 14, 2022. 
 
You asked the Plan to pay for the annual wellness visit. You say that you were supposed to have a routine 
physical. The Plan denied your request. The Plan says the services exceed your benefit limit. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
You previously received an AWV on March 3, 2021. Therefore, we decided that the Plan does not have to pay 
for the annual wellness visit received on February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for massage therapy provided from December 23, 2021, through 
March 1, 2022. 
 
You asked the Plan to pay for massage therapy. You say that you were told by letter that massage therapy was 
covered. The Plan denied your request. The Plan says Medicare guidelines states that massage therapy provided 
by a licensed massage therapist is not covered. Massage therapy is only covered under specific conditions, 
which are when provided by a physical therapist within a physical therapy program. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pay for massage therapy provided from December 23, 2021, through 
March 1, 2022.
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 a lower level of care would not provide the patient 
with the level of rehab required. The Plan denied your request. The Plan says the patient does not require IRF 
level of care and he can be managed at a lower level of care. 
 
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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for back pain after a fall and was discharged to assisted living facility on July 13, 2022. Their medical 
problems are stable and 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 medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy office visit (90832) provided on December 
21, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a psychotherapy office visit. You say that the office visit was medically 
necessary, and you have enclosed medical records for review and reconsideration of this claim. The Plan 
denied your request. The Plan says a provider must attempt to consult the attending or primary care physician 
about the services furnished and document the consent or declination date to consultations, and the date of 
consultations in the patients medical record. There was no documentation of contact in the patient record. 
 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 a psychotherapy office visit (90832) provided on 
December 21, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services provided to the enrollee on October 4, 
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 services were not authorized. 
 
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 injection services provided to the enrollee on 
October 4, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal facet joint radiofrequency ablation.  
You asked the Plan to pre-approve thermal facet joint radiofrequency ablation. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered when specific 
criteria are met. 
 
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 thermal facet joint radiofrequency 
ablation. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is 
no documentation of prior diagnostic medial branch block (MBBs) or prior radiofrequency ablation (RFA). 
Therefore, the request does not meet the LCD criteria. The request 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 thermal facet joint radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve thermal facet joint radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint interventions. 
 
You asked the Plan to pre-approve facet joint interventions. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for the 
requested facet joint injections. 
 
The Plan follows Medicare rules. Medicare rules state that facet joint interventions are only covered if certain 
criteria are met. 
 
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 facet joint interventions. Our reviewer 
says that the enrollee does not meet the Medicare criteria for the requested facet joint injections. Our physician reviewer found there are no imaging studies that show the enrollee does not have any non-facet 
pathology. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint interventions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint interventions.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a posterior chamber intraocular lens received on February 
11, 2021. 
 
You asked the Plan to pay for the services. You say that you were advised that everything is covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for a posterior chamber 
intraocular lens received on February 11, 2021.