Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
(E0730) provided on August 27, 2022. 
 
You asked the Plan to pay for the TENS unit. You say that the claim was billed in allowance with the enrollee's 
plan's policy allowable, accepted procedure codes, and diagnosis codes. The Plan denied your request. The Plan 
says the TENS is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that transcutaneous electrical nerve stimulation 
(TENS) is not reasonable and necessary for the treatment of chronic low back pain (CLBP).  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the TENS unit have not been met. Therefore, we decided that the Plan does not have to pay for the 
transcutaneous electrical nerve stimulation (TENS) (E0730) provided on August 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 09, 2022. 
 
You asked the Plan to pay for the office visit. You say that you were not advised that a referral was required for 
specialist visits. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on November 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on December 28, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
December 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth visit provided on January 12, 2023. 
 
You asked the Plan to pay for telehealth visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for telehealth visit provided 
on January 12, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 You asked the Plan to pre-approve home health skilled nursing services. You say that the medical records 
provided support the need for the skilled nursing services. The Plan denied your request. The Plan says the 
services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health skilled nursing services. 
Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found 
the enrollee does not have documented skilled nursing needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health skilled nursing services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve home health skilled nursing services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest. 
 
You asked the Plan to pre-approve CT scan of the chest. You say that the CT scan is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 CT scan. Our reviewer says that the CT 
scan is not medically necessary. Our physician reviewer found the clinical notes received do not show medical 
necessity for a third chest CT scan. A nodule smaller than 6 millimeters that has shown no increase in size after 
an interval of 5 months does not require follow up sooner than 1 year. The denial is upheld. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomography (CT) scan of the chest.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on June 02, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
June 02, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 28, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on September 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (ECG) provided on August 19, 2022. 
 
You asked the Plan to pay for an electrocardiogram (ECG). You say that this was an emergency and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an electrocardiogram 
(ECG) provided on August 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination, chest; single view (X-ray), 
provided on August 20, 2022, billed with procedure code 71045. 
 
You asked the Plan to pay for the x-ray. You say that the claim denied as a duplicate in error. The Plan denied 
your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on September 21, 2022. Comparison of the two claims shows these are exact 
duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the x-ray have not been met. 
Therefore, we decided that the Plan does not have to pay for a radiologic examination, chest; single view (X-
ray), provided on August 20, 2022, billed with procedure code 71045.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) study of the 
cervical spine. 
 
You asked the Plan to pre-approve the MRI study. You say that the services are medically necessary. The plan 
denied your request. The Plan says a request like this one has been approved. The plan needs the results of the 
approved MRI to show medical necessity for repeat imaging. 
 
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 the MRI study. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found you have neck pain and left arm tingling. 
Your neurological exam was normal. Your computed tomography (CT) scan showed severe degenerative 
spondylosis. There is no documentation of a 6-week trial of physical therapy. Medical necessity for the MRI 
has not been established in the medical records. 
 
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 MRI study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a magnetic resonance imaging (MRI) study of the cervical spine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you want to return to being independent and are 
eager to participate in the aggressive rehabilitation an IRF will offer you. You say you will not get that at a 
nursing home, and that your doctor says you will also need closer medical management of your current medical 
needs and disease. The Plan denied your request. The Plan says the requested IRF admission 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 the complexity of your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
weakness, difficulty walking, and back pain. Your medical problems are stable and there are no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While you may have a need 
for physical therapy 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 you 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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology procedure provided on December 19, 2022.

You asked the Plan to pay for molecular pathology procedure. You say that you are requesting reconsideration. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered.

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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for molecular pathology procedure provided on December 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2377, E2300). 
 
You asked the Plan to pre-approve additional power wheelchair accessories. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that services are covered if they are medically necessary. 
Medicare rules say that a power seat elevation feature (E2300) is not covered because it is primarily medical in 
nature. 
 
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 additional power wheelchair 
accessories. Our reviewer says that the requested items are not medically necessary. Our physician reviewer 
found the enrollee has adequate left upper extremity strength and function to operate the wheelchair's power 
options with their own switches. 
 
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 power wheelchair accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, 
E2377, E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown - porcelain/ceramic tooth #30 (D2740), and core 
buildup, including any pins when required tooth #30 (D2950) provided on November 19, 2022. 
 
You asked the Plan to pay for D2740 tooth #30, and D2950 tooth #30. You say that you have discussed this 
matter with the dentist and he states the teeth do meet criteria for crowns. You also say the Plan should call him 
to discuss this matter. The Plan denied your request. The Plan says the services are not medically necessary. 

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. The Plan covers D2740 tooth 
#30, and D2950 tooth #30 when the services are medically necessary and reasonable.  
 
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 D2740 tooth #30, and D2950 tooth #30. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the criteria for 
coverage have not been met. Due to the poor quality of the radiographs provided a determination of the need 
for a crown restoration for tooth #30 could not be made. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of D2740 tooth #30, and D2950 tooth #30 have not been met. Therefore, we 
decided that the Plan does not have to pay for a crown - porcelain/ceramic tooth #30 (D2740), and core 
buildup, including any pins when required tooth #30 (D2950) provided on November 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a headrest adaptor (K0108), tray hardware (K0108), 
bracket head support (K0108), gel pads (K0108), power seat elevation (E2300), power standing system 
(E2301), attendant control (E2331), and a safety belt (E0978). 
 
You asked the Plan to pre-approve the headrest, tray hardware, head support, power seat elevation, power 
standing system, attendant control, safety belt, and gel pads. You say that you need a whole new wheelchair. 
The Plan denied your request. The Plan says that these items are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules also say that if an attendant control (E2331) is provided in addition to a beneficiary-
operated drive control system, it will be denied as non-covered. 
 
The power seat elevation (E2300) and the power standing system (E2301) do not serve a purpose that is 
primarily medical in nature. The headrest hardware (K0108), tray hardware (K0108), gel pads (K0108), and 
safety belt (E0978) are included in other approved codes and are not separately payable. An attendant control 
(E2331) is not covered if a user-operated control is requested. Therefore, we decided that the Plan does not 
have to pre-approve a headrest adaptor (K0108), tray hardware (K0108), bracket head support (K0108), gel 
pads (K0108), power seat elevation (E2300), power standing system (E2301), attendant control (E2331), and a 
safety belt (E0978).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from March 31, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from March 31, 2023, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from March 
31, 2023, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of March 31, 2023, forward. Our physician reviewer found you did not 
require inpatient mental health treatment beyond March 31, 2023, as you were not a danger to yourself or 
others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment 
was taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from March 31, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from March 31, 
2023, forward.