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

 
We decided that the Plan does not have to pre-approve Dupixent (C9399). 
 
You asked the Plan to pre-approve the Dupixent. You say that this drug is medically necessary. The Plan 
denied your request. The Plan says this drug is not eligible for coverage under the Part B medical 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 Dupixent (C9399).  
 
Benefits for the Dupixent 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan (72131) provided on 
April 6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the CT scan. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
  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 computed tomography (CT) scan (72131) 
provided on April 6, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on October 24, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates that these tests should be included in the dialysis rate. The Plan denied 
your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on October 
24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically stable and will 
benefit from an LTACH admission. The Plan denied your request. The Plan says the member does not meet the 
criteria for an LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current healthcare setting being offered by the Plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
  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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve testosterone undecanoate. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that testosterone is 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
hypogonadism. The records do not document at least two separate serum testosterone levels taken on two 
different days in the morning and/or two morning levels of "free" or bioavailable testosterone and elevated 
luteinising hormone (LH) or follicle stimulating hormone (FSH)  levels. The criteria for coverage are not met 
and the requested treatment is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve testosterone undecanoate.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF is not medically necessary. 
 
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 that the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of  rehabilitative services and regular physician evaluations. The enrollees care needs can be met at a lower level 
of care. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a catheter placement in coronary artery(s) for coronary 
angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and 
interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, 
when performed (93458). 
 
You asked the Plan to pre-approve left heart catheterization. You say that you disagree with the denial. The 
Plan denied your request. The Plan says left heart catheterization is not recommended unless there is evidence 
of at least mild ischemia on imaging or significant obstructive coronary artery disease on CCTA. 
 
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 left heart catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found at issue is the medical appropriateness and necessity for performance of cardiac 
catheterization. The enrollee had a negative radionuclide stress test in January 2023, as well as an 
echocardiogram which showed preserved ventricular function. Documentation does not support the rationale 
for this invasive imaging study. Guidelines do not support a need for cardiac catheterization in this setting. As a 
result, at this time cardiac catheterization would not be considered medically appropriate and necessary in this 
enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of left heart catheterization. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a catheter placement in coronary artery(s) for coronary angiography, 
including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with 
left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed 
(93458).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair (E2201, K0005, E0978, E2203). 
 
You asked the Plan to pre-approve the manual wheelchair. You say that the manual wheelchair is medically 
necessary. The Plan denied your request. The Plan says a power wheelchair was already provided and serves 
the same purpose. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a power wheelchair. The power wheelchair serves the same purpose as the manual 
wheelchair. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair (E2201, 
K0005, E0978, E2203).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH are medically necessary. The 
Plan denied your request. The Plan says that the admission to a LTACH is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation provided indicating the medical necessity for 
admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving care. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual depression screening provided on  
October 24, 2022. 
 
You asked the Plan to pay for the annual depression screening. The Plan denied your request. The Plan says the 
Plan paid for an annual depression screening for date of service March 29, 2022. The visit exceeds the benefit 
limit of one screening annually. 
 
The Plan contract says that the Plan covers one screening for depression per year. 
 
We looked at the file and Plans rules. The file shows that you have exceeded the benefit limit of one screening 
for depression per year. Therefore, we decided that the Plan does not have to pay for an annual depression 
screening provided on October 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve resin-based composites-three surfaces, posterior  
(D2393 x 4) and resin-based composites-one surface, posterior (D2391 x 2). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested items has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested items was exhausted on date of service January 12, 2023. Specifically, the 
Plan contract says that four procedures are covered every calendar year for dental codes D2140-D2394. You 
previously received four resin-based composites-three surfaces, posterior (D2393 x 4) on January 12, 2023. 
Therefore, you have exhausted the allowable benefit for these items. Therefore, we decided that the Plan does 
not have to pre-approve resin-based composites-three surfaces, posterior (D2393 x 4) and resin-based 
composites-one surface, posterior (D2391 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a catheter placement in coronary artery(s) for coronary 
angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and 
interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, 
when performed (93458). 
 
You asked the Plan to pre-approve left heart catheterization. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the left heart catheterization is not recommended unless there is 
evidence of at least mild ischemia on imaging or significant obstructive coronary artery disease on CCTA. 
 
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 left heart catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found at issue is the medical appropriateness and necessity for performance of cardiac 
catheterization. The enrollee had a prior history of chest pains, now resolved, with a negative radionuclide 
stress test in February 2023, as well as an echocardiogram which showed preserved ventricular function. 
Documentation does not support the rationale for this invasive imaging study. Guidelines do not support a need 
for cardiac catheterization in this setting. As a result, at this time cardiac catheterization would not be 
considered medically appropriate and necessary in this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of left heart catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a catheter placement in coronary artery(s) for coronary angiography, including 
intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart 
catheterization including intraprocedural injection(s) for left ventriculography, when performed (93458).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6533 that 
were issued on September 9, 2022. 
 
You asked the Plan to pay for the compression stockings. You say that the items should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the items denied correctly as they were 
over the counter. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6533 that were issued on September 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 6, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement in place which indicates that these services are included in the dialysis rate. The Plan 
denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 6, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0823, E2365, E0973). 
 
You asked the Plan to pre-approve the power wheelchair. You say that this power wheelchair is medically 
necessary. The Plan denied your request. The Plan says the record shows this equipment is primarily for use 
outside the home and is therefore 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 power wheelchair (K0823, E2365, E0973).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for emergency room services provided in Mexico on 
July 13, 2022. 
 
You asked the Plan to reimburse you for emergency room services. You say that you had to go to Mexico to 
have surgery on your arm because the in-network specialists did not want to see you and give you an 
appointment. The Plan denied your request. The Plan says you did not submit proof of payment and/or an 
itemized statement showing what procedures were done and what was paid. 
 
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 emergency room services have been 
met. Specifically, there is no proof of payment and/or an itemized statement showing what procedures were 
done and what was paid. Therefore, we decided that the Plan does not have to reimburse you for emergency 
room services provided in Mexico on July 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212) provided on April 10, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician service. You say that this visit was to make sure that the enrollee's 
nerve block had resolved. You also say that this should be covered. The Plan denied your request. The Plan 
says prior authorization was not obtained. 
 
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 provider in this case is not a network provider with the Plan. 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 office visit (99212) provided on April 10, 2022, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an initial comprehensive preventive medicine evaluation and 
management exam provided on August 5, 2022. 
 
You asked the Plan to pay for an initial comprehensive preventive medicine evaluation and management exam. 
You say that you have been looking for a primary care doctor for over a year and this service was to get 
established as a patient. The Plan denied your request. The Plan says you have exceeded your benefit limit 
because you had an initial comprehensive preventive medicine evaluation and management exam on 
June 6, 2022. 
 
The Plan contract covers comprehensive preventive medicine evaluation and management. The Plan says a 
comprehensive preventive medicine evaluation and management exam is covered once per year. 
 
We looked at the file and the Plans rules. The file shows that you have exceeded the benefit limit. Therefore, 
we decided that the Plan does not have to pay for an initial comprehensive preventive medicine evaluation and 
management exam provided on August 5, 2022.