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

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the brain 
(70551). 
 
You asked the Plan to pre-approve MRI of the brain. You say that this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI of the brain. Our reviewer says 
that the requested imaging service is not medically reasonable and necessary. Our physician reviewer found the 
record indicates that the enrollee has a one-month history of memory issues. The record does not indicate the 
occurrence of acute injury. The record does not include a neurologic or mental status examination. The 
requested service is not medically necessary and reasonable for the diagnosis and treatment for the enrollee's 
clinical condition at this time. 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 MRI of the brain have not been met. Therefore, we decided that the Plan does 
not have to pre-approve magnetic resonance imaging (MRI) of the brain (70551).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for this enrollee. The 
Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can 
safely receive the services they need in 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
documentation does support a need for physical and/or occupational therapy, there is no documented need for 
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computerized knee (L5814, L5848, L5850, and 
L5845). 
 
You asked the Plan to pre-approve a computerized knee. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of knee. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 computerized knee. Our reviewer says 
that the item is not medically necessary. Our physician reviewer found you are improving with physical therapy 
and you are currently using a rolling walker and starting to use a straight cane to some extent. You are 
independent with your exercises and your records do not show a failure with a non-computerized prosthesis. 
 
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 computerized knee have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computerized knee (L5814, L5848, L5850, and L5845).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve (12) visits of services performed by a qualified 
physical therapist to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that no other home health agency in 
your area is accepting your insurance. You state this provider can service you as soon as the gap extension is 
approved. The Plan denied your request. The Plan says medically necessary services are available within your 
network and there are no extenuating circumstances making it medically necessary to obtain the routine service 
out-of-network. 
 
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 twelve (12) visits of services performed by a 
qualified physical therapist to be provided by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transfer to 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 enrollee is receiving adequate and necessary intensive rehabilitation in the 
inpatient rehabilitation facility (IRF). The Plan states all the services the enrollee needs are offered at the IRF. 
The Plan states transfer to a SNF for inpatient skilled rehabilitation services is not medically necessary.  
 
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 reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided there is 
documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, knowledge and 
judgment of a skilled professional nurse are required to safely and effectively provide medically necessary and 
reasonable treatment. This enrollee does require skilled therapy services, i.e., the specialized skill, knowledge 
and judgment of a qualified therapist are required to safely and effectively provide medically necessary and 
reasonable treatment. Daily skilled services are required. This enrollee does not require the services on an 
inpatient basis, only in a skilled nursing facility setting. Continued services in the acute inpatient rehabilitation 
facility appear appropriate in this case (and are endorsed by the health plan) until the enrollee is stable to 
transfer to a lower level of care such as home with home health 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve transfer to SNF care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from November 6, 2021, 
forward. 
 
You asked the Plan to pre-approve SNF care. You say that termination of treatment was not appropriate. You 
state the enrollee has not reached the level of movement and mobility that they had prior to incident. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided there is 
no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, knowledge and 
judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary 
and reasonable treatment. This enrollee does require skilled therapy services, i.e., the specialized skill, 
knowledge and judgment of a qualified therapist are required to safely and effectively provide medically 
necessary and reasonable treatment. Daily skilled services are not required. This enrollee does not require the 
services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health 
care or in a long-term care facility on a part time basis appear appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continuation of SNF care from November 6, 2021, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator rentals (K0606) rendered 
by the out-of-network (OON) provider on January 4, 2021 and February 4, 2021. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the items were rendered by an out of network 
provider, without prior authorization. 
 
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 had network providers available 
who could have provided the items at issue in this appeal. The Plan did not pre-approve the items at issue.  
We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan 
does not have to pay for the automatic external defibrillator rentals (K0606) rendered by the out-of-network 
(OON) provider on January 4, 2021 and February 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for cataract surgery (66984) provided on April 12, 2021, by an 
out-of-network provider. 
 
You asked the Plan to pay for cataract surgery. You say that the requested services were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met. 
 
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 cataract surgery (66984) provided on April 12, 
2021, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on June 15, 2021, by an OON
provider.
You asked the Plan to pay for the drug testing. You say that you were not aware a prior authorization was
required, and the service was medically necessary. The Plan denied your request. The Plan says no prior
authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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 did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the drug testing provided on June 15, 2021, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenomic testing provided on June 3, 2021. 
 
You asked the Plan to pay for the pharmacogenomic testing. You say that you would like reconsideration 
because this testing was medically necessary. The Plan denied your request. The Plan says if there is no 
HCPCS/CPT code that describes the procedure, the laboratory shall report a miscellaneous or unlisted 
procedure code with a single unit of service. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the pharmacogenomic testing, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. The documentation does not show that the 
requested pharmacogenomic testing was ordered due to any signs/symptoms of a drug reaction. There is no 
evidence that the testing was provided for therapeutic decision-making regarding the need for the use of any 
specific drug. Therefore, we decided that the Plan does not have to pay for the pharmacogenomic testing 
provided on June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the paring or cutting of benign hyperkeratotic lesions 
(11056), the nail debridement (11721), and the office visit (99214) rendered by an out-of-network (OON) 
provider on April 7, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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. 

You are not a network provider with the Plan. The Plan had network providers available who could have 
provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no 
exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not 
have to pay for the paring or cutting of benign hyperkeratotic lesions (11056), the nail debridement (11721), 
and the office visit (99214) rendered by an out-of-network (OON) provider on April 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for a wheelchair. 
 
You asked the Plan to pre-approve the referral. You say that you are in the process of negotiating to become a 
contracted provider. The Plan denied your request. The Plan says there is a network provider 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 out-of-network referral for a wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the breast implant removal procedure. 
 
You asked the Plan to pre-approve the breast implant removal procedure. You say that this requested procedure 
is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for 
coverage for the requested procedure have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that breast implant removal is subject to the criteria listed 
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 the breast implant removal procedure. 
Our reviewer says that the requested procedure is not medically reasonable and necessary according to the 
Medicare criteria. Our physician reviewer found that in this case the record indicates that the enrollee had 
saline implants placed over 20 years ago. The record indicates that the enrollee has ptosis causing cervical and 
thoracic pain and bra strap notching. The record does not indicate that the enrollee has broken or failed implant, 
infection, implant extrusion, siliconoma or granuloma, interference with diagnosis of breast cancer, painful 
capsular contracture with disfigurement. The elements of the coverage criteria are not satisfied.  
 
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 breast implant removal procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the breast implant removal procedure.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the endolumenal functional lumen imaging probe 
(EndoFLIP) procedure. 
 
You asked the Plan to pre-approve the EndoFLIP. You say that the EndoFLIP is FDA approved to diagnose 
motility disorders. It is being used in concert with endoscopy, manometry and timed barium esophgram to 
properly diagnose the patient's motility disorders. The Plan denied your request. The Plan says the enrollee 
does not meet criteria. EndoFLIP testing for diagnosis, prognosis, or guidance of the management of achalasia, 
eosinophilic esophagitis, and gastroparesis is considered investigational and unproven. 
 
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 EndoFLIP procedure. Our reviewer 
says that the EndoFLIP procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee's dysmotility has been characterized over two years by three serial 
imaging's that include barium studies x2 and computed tomography (CT) scan.  The available records support 
those findings are little changed in the interval. The medical necessity for additional motility testing in the form 
of the proposed EndoFLIP procedure, as opposed to planned conventional manometry is not demonstrated. 
 
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 EndoFLIP procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the EndoFLIP procedure.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 12, 
2021. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered a screening procedure and therefore not covered. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the review indicates that Medicare considers vitamin assay panels (more than one vitamin assay) a 
screening procedure and therefore, non-covered. The review has determined that the services at issue in this 
case are 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the amalgam (D2150) provided on July 7, 2021. 
 
You asked the Plan to pay for the dental service. You say that your tooth was causing you pain. You say that 
this service should be covered. You also say that this service was medically necessary. The Plan denied your 
request. The Plan says the amalgam is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the amalgam is not among those 
covered under this benefit. Additionally, the record shows that you did not elect to purchase the additional 
supplemental coverage. Therefore, we decided that the Plan does not have to pay for the amalgam (D2150) 
provided on July 7, 2021.