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

 
We decided that the Plan does not have to pre-approve a positron-emissions tomography (PET) scan. 
 
You asked the Plan to pre-approve a PET scan. You say that a PET scan is medically necessary. The Plan 
denied your request. The Plan says the patient does not meet coverage criteria for a PET scan. 
 
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 a PET scan. Our reviewer says that the 
requested PET scan is not medically necessary. Our physician reviewer found Medicare does not permit 
coverage of PET scans in the initial treatment of melanoma as a staging procedure without a history of positive 
nodes.  In this patient, the positive diagnosis has been made but there are no palpable nodes and a sentinel node 
study has not been done nor has there been a positive node biopsy.  While the use of PET to evaluate lymph 
nodes for metabolic activity and hence way to evaluate for possible occult metastatic disease, Medicare does 
not permit the use of PET in such a manner in cases of melanoma. 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron-emissions tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device. 
 
You asked the Plan to pre-approve a pneumatic compression device. 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 pneumatic compression devices 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 a pneumatic compression device. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that the segmented pneumatic compression device and related 
accessories at issue in this case meet all of Medicare's NCD criteria for medically reasonable and necessary for 
the enrollee. Provided records do not document the enrollee has had one or more venous stasis ulcer(s) which 
have failed to heal after a 6-month trial of conservative therapy directed by the treating physician as required by the NCD. As records do not document the enrollee has lymphedema extending onto the trunk, pelvis or 
chest and as a trial and failure of a standard pneumatic compression pump has not been documented, then it 
cannot be said that the enrollee has unique characteristics that would indicate a segmented pump over a 
standard pump. 
 
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 pneumatic compression device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a pneumatic compression device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmic biometry provided on May 23, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmic biometry. You say that you are out-of-network with the Plan, so no 
pre-certification was obtained prior to the visit. The Plan denied your request. The Plan says the rendering 
provider is a non-participating provider. The Plan also says that they did not authorize any services for this 
facility or this provider. 
 
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 ophthalmic biometry provided on May 23, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transport chair. 
 
You asked the Plan to pre-approve these services. You say that the chair will help you go out and be social with 
friends. The Plan denied your request. The Plan says the services are not covered. 
 
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 transport chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and consultation with an ophthalmologist 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit and consultation with an ophthalmologist. You say that a few 
years ago an ophthalmologist told you that you have the beginnings of cataracts. You also say that because of 
this, you would like advice concerning cataracts' removal. The Plan denied your request. The Plan says their 
network providers provide this service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit and consultation with an ophthalmologist to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you are appealing the Plan's decision. The Plan 
denied your request. The Plan says you must receive your care from a network provider. 
 
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 to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home delivered, prepared meals (S5170). 
 
You asked the Plan to pre-approve home delivered, prepared meals (S5170). You say that your attending 
physician from the hospital ordered this medical service. You also say that you live along and find it difficult, if 
not impossible to cook meals for yourself as you have extremely low energy, and the oxygen complicates your 
ability to move. The Plan denied your request. The Plan says the member was not admitted with the qualifying 
diagnosis of congestive heart failure for coverage of the meal plan supplemental benefit. 
 
The Medicare rules say that meals may be offered as a supplemental benefit for certain conditions. However, 
the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in 
this case. The Plan covers home delivered meal benefits only when there is a referral, and the enrollee is being 
discharged from the hospital as an inpatient due to congestive heart failure.  
The Plans rules for coverage of home delivered meal benefits have not been met because the Plan covers 
home-delivered meals following a discharge from a hospital as an inpatient due to congestive heart failure. The 
record shows that you did not get discharged with congestive heart failure. Therefore, we decided that the Plan 
does not have to pre-approve home delivered, prepared meals (S5170).
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollee was admitted for surgical repair of a hip fracture after a fall. There are no 
complex nursing or rehabilitation needs. The enrollee 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 the enrollee 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100). 
 
You asked the Plan to pre-approve additional non-emergency transportation (A0100). You say that you live 
alone and have no one to give you some support. You also say that you have several medical problems. The 
Plan denied your request. The Plan says your plan covers 12 one-way trips. The Plan also says that you have 
used all of your trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 12 trips every year trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genicular nerve block provided on June 23, 2022. 
 
You asked the Plan to pay for the genicular nerve block. You say that this service should be covered. The Plan 
denied your request. The Plan says the genicular nerve block is experimental/investigational. 
 
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 genicular nerve block. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the role of genicular nerve blocks and radiofrequency ablation is still being 
evaluated. It is considered experimental/ investigational. Therefore, the procedure was 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pay for the genicular nerve block provided on June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medical eye examination (92014), scanning 
computerized ophthalmic diagnostic imaging (92134), intravitreal injections of a pharmacologic agent (67028), 
and  bevacizumab injections. 
 You asked the Plan to pre-approve a medical eye examination (92014) and an eye injection. You say that you 
are losing your vision. You also say that this provider, who is a retina specialist, gives you injections every six 
weeks to keep your vision from getting worse, and he does not hurt you when giving the injections. The Plan 
denied your request. The Plan says this provider is not a network provider. The Plan also says that they will 
approve the office visit and eye injection with a network provider. 
 
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 covers these services when they are provided with a prior authorization from a Plan 
specialist. 
 
We looked at the file and the Plan's rules. This provider is not in-network and there are in-network providers 
available. Based on this information, we decided that the Plan's rules for coverage of a medical eye 
examination (92014) and an eye injection have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a medical eye examination (92014), scanning computerized ophthalmic diagnostic imaging 
(92134), intravitreal injections of a pharmacologic agent (67028), and  bevacizumab injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee is a patient under my care for 
the management of her acute on chronic respiratory failure. He suffers from COPD and acute on chronic 
hypercapnic respiratory failure, both of which have significantly impaired his ability to ventilate. The Plan 
denied your request. The Plan says use of a portable ventilator to deliver ventilatory support via settings that 
could be equally provided by a BiPAP with AVAPS-AE settings is inconsistent with Local Coverage 
Determination: Respiratory Assist Devices (L33800). The requested device would be used in a BiPAP mode 
that could be provided with a BiPAP (E0471) device with AVAPS-AE added to assure adequate tidal volumes. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has chronic hypoxemic respiratory failure from chronic obstructive pulmonary disease. 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 coverage for such a device is available upon request. 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 home health physical therapy visits. 
 
You asked the Plan to pre-approve 10 home health physical therapy visits. 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 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 10 home health physical therapy visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the 
medical records provided there is no documentation that further skilled physical therapy services are required 
per Medicare criteria (Medicare Benefit Policy Manual, Chapter 7). Provided records do not document any 
acute or unstable medical conditions or changes in medication or treatment which would necessitate any further 
skilled therapy visits beyond what have already been approved. Records document the enrollee has been 
educated on her disease process and home exercise program. No medical notes from the enrollees treating 
physician are provided documenting an order or need for additional skilled therapy 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 10 home health physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 10 home health physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dermatology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve dermatology services. You say that you have been under this provider's care 
for over 7 years, that this is the only provider that has been able to treat your condition, and you do not trust 
any other provider because of your past history. The Plan denied your request. The Plan says you must get your 
care from network providers that are affiliated with your PCPs medical group. 
 
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 
dermatology services 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 pre-approve additional physical therapy (PT) visits (97139x999). 
 
You asked the Plan to pre-approve additional PT visits. You say that the enrollee needs physical therapy to 
meet goals for skilled nursing. The Plan denied your request. The Plan says though the enrollee would benefit 
from continued therapy to address flexibility, strength, and standing balance, the requested number of sessions 
is not reasonable. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve PT visits. Our reviewer says that skilled 
services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
Our physician reviewer found the requested physical therapy is generally accepted as a specific and effective 
therapy for the treatment of knee and hip pain as well as difficulty walking. As of 9/2/2022, the enrollee had 11 
sessions of physical therapy. Range of motion at the left knee was noted to be 120 degrees and 110 degrees at 
the right knee. Motor strength was noted to be 3+/5 bilaterally at the knee joints. This was the same as the 
previous dates. The enrollee was independent with mobility. He was performing dynamic strengthening 
exercises in therapy. The enrollees progress had plateaued in terms of his objective outcome measures, 
including his lower extremity functional scale score. He did not require the services of a skilled physical 
therapist and could have continued to build strength and endurance with a home exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy (PT) visits (97139x999).