Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy (PT) visits (G0151). 
 
You asked the Plan to pre-approve the PT visits. You say that you want to continue with PT. The Plan denied 
your request. The Plan says there was no documentation received showing that the requested home health PT 
visits are being ordered by your doctor and medically necessary. 
 
  The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of home health physical therapy (PT) 
visits have been met. Medical records were not provided for this case. The Plan asked for these documents, but 
they were not provided. Without this information we cannot determine that the requested PT visits are 
medically necessary. Therefore, we decided that the Plan does not have to pre-approve home health physical 
therapy (PT) visits (G0151).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair with accessories (E0954, E2323, 
E2313, E2377, E0960, K0108, E0953, E0955, K0040, E1012, E2625, E1028, E0956, E2620, E2311, E1007, 
E2359). 
 
You asked the Plan to pre-approve the power wheelchair with accessories. You say that this power wheelchair 
is medically necessary. The Plan denied your request. The Plan says the records show you reside in a skilled 
nursing facility. Equipment used in a skilled nursing facility is not eligible for separate coverage. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the power wheelchair with accessories is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a power wheelchair with accessories (E0954, 
E2323, E2313, E2377, E0960, K0108, E0953, E0955, K0040, E1012, E2625, E1028, E0956, E2620, E2311, 
E1007, E2359).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for provision of the services of a Medicare-enrolled opioid 
treatment program provided to the enrollee on February 7, 2022. 
 
You asked the Plan to pay for . You say that the billing was correct. The Plan denied your request. The Plan 
says this was not billed with the correct type of bill. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly, with the 
correct bill type. 
 
 
 
 
 
 The file does show that these services were reported on the correct bill type. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for provision of the services of a Medicare-enrolled opioid treatment program provided to the enrollee 
on February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye examination with fundus photography (92250) 
provided on March 22, 2022. 
 
You asked the Plan to pay for an eye examination with fundus photography. You say that you were told that the 
service would be covered. The Plan denied your request. The Plan says the service at issue is not covered when 
an out-of-network provider is utilized.  
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 you use a network provider. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of eye examination with fundus photography have not been met. Specifically, services were rendered 
by and out-of-network provider and are not covered. Therefore, we decided that the Plan does not have to pay 
for an eye examination with fundus photography (92250) provided on March 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transesophageal echocardiogram (TTE) (93306) provided 
on July 9, 2021. 
 
 
You asked the Plan to pay for the TTE. You say that the medically necessary services were rendered to the 
enrollee in good faith. The Plan denied your request. The Plan says the service in this case is not medically 
necessary. 
 
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 TTE. Our reviewer says that the TTE is not considered medically reasonable and necessary in this case. Our physician reviewer found the provided 
documentation does not indicate any clinical history or remarkable physical examination. Therefore, the 
reviewer found that there is no supportive evidence for the medical necessity of the transesophageal 
echocardiogram (TTE) 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 the TTE have not been met. Therefore, we decided that the Plan does not have 
to pay for the transesophageal echocardiogram (TTE) (93306) provided on July 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22869). 
 
You asked the Plan to pre-approve the surgery. You say that the enrollee has tried conservative treatments that 
have not worked. The Plan denied your request. The Plan says the Medicare criteria for reasonable and 
necessary are not met as it has not been shown to be safe and effective in long term studies and there is a lack 
of evidence to support that interspinous spacer devices are as safe and effective as the gold standard of 
decompression. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. More research is needed. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper and lower partial dentures. 
 
You asked the Plan to pre-approve the requested dentures. You say that you cannot wear your dentures. The 
Plan denied your request. The Plan says your benefit has 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. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested dentures was exhausted on July 29, 2022. Therefore, we decided that the 
Plan does not have to pre-approve upper and lower partial dentures.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on April 18, 
2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that the lab tests should be covered. 
The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment per day for laboratory tests that are not FIT tests.  
 
You have been asked to pay a $10 copayment for the lab services. The lab services fall within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for laboratory services provided on April 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and an electrocardiogram provided on January 
24, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and an electrocardiogram. You say that the secretary mistakenly 
placed the year 2021 on the payment receipt, so the Plan denied the request. The Plan denied your request. The 
Plan says the request was denied due to the provider is not contracted, there is no evidence of preauthorization, 
there are contracted providers in the area, and there is no primary care physician (PCP) referral. 
 
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 an office visit and an electrocardiogram provided 
on January 24, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for CT scan and DME provided on February 14, 
2022. 
 
You asked the Plan to waive the cost share for CT scan and DME. You say that you feel you do not owe this 
amount. The Plan denied your request. The Plan says the cost share applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment and $225 copayment for advanced imaging. 
 
 You have been asked to pay $41.37 which is 20% of the allowed amount for the DME. You have been asked to 
pay $225 copayment for the CT scan. The total amount you have been asked to pay is $266.37. DME falls 
within the Durable Medical Equipment (DME) and Related Supplies benefit category.  The CT scan falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the cost share for CT scan and DME provided on February 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve True Metrix diabetic test strips (A4253). 
 You asked the Plan to pre-approve True Metrix test strips. You say that the requested item is a necessity for the 
enrollee's care. The Plan denied your request. The Plan says rules for coverage for diabetic supplies have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MA Plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of True Metrix test strips have not been met. Specifically, the requested item is a non-preferred brand. 
The case record does not contain medical documentation to support the medical necessity of the requested item. 
Therefore, we decided that the Plan does not have to pre-approve True Metrix diabetic test strips (A4253).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the revascularization of both lower legs (CPT code(s): 
37225 and 37229). 
 
You asked the Plan to pre-approve the revascularization. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the revascularization. Our physician 
reviewer found the enrollee has no current evidence of limb threat. The enrollee has numerous comorbidities 
including diabetes with diabetic neuropathy, chronic kidney disease, and most poorly, significant history with 
respect to their spine including a history of back surgery with nonresolution of their symptoms and 
documentation that the enrollee walks hunched over. Efforts at attempting conservative treatment are not 
documented.  Based on the current documentation, it is not possible to overturn the health plan determination 
on the basis of medical necessity. 
 
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 revascularization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the revascularization of both lower legs (CPT code(s): 37225 and 37229).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says your request is not medically necessary because there is little evidence 
in the medical literature to suggest that this is an appropriate procedure for the enrollee's back pain. The Plan 
states it is not an accepted standard of medical practice for the diagnosis or treatment of back pain and it is 
considered experimental and 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 pre-approve the intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. More research is needed. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (CPT code 64628).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 care. Our physician reviewer 
found the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing 
needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be 
required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees care needs appear to be custodial and can, as a practical matter, be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the incontinence garments are medically 
necessary. The Plan denied your request. The Plan says this item is non-covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
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 you need assistance getting strength in your legs and 
this will not be accomplished in a nursing home. The Plan denied your request. The Plan says services 
requested do not meet medical necessity 
 
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 you do not have complex or intensive rehabilitation needs and you could not reasonably be expected to return to the community after a rehabilitation stay. There is no indication for 
frequent physiatry oversight. The criteria for coverage are not met. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you became weaker since being in the hospital. You 
state that you need strengthening and endurance to be more independent to return home. The Plan denied your 
request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 care. Our physician reviewer 
found you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. 
Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your 
condition. Your care needs, custodial and intermittent, can, as a practical matter, be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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. The Plan denied your request. The Plan says 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 were admitted to the acute care hospital for surgical repair of the hip after a fall. Your medical 
problems are stable. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat (E0244). 
 
You asked the Plan to pre-approve a raised toilet seat. You say that the requested item is a medical necessity 
for you. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat (E0244).