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

 
We decided that the Plan does not have to pre-approve left atrial appendage closure (LAAC) surgery. 
 
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 LAAC 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 records do not show that you have a 
contraindication to use of anticoagulation. The criteria for coverage are not met; therefore, the LAAC 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 left atrial appendage closure (LAAC) surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power mobility device tire and caster replacement. 
 
You asked the Plan to pre-approve power mobility device repairs. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says damage to the enrollee's tires and casters do 
not appear to be the result of normal wear and tear, and there is no statement from the ordering physician 
documenting a rationale for replacement of tires and casters. 
 
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 power mobility device tire and caster 
replacement. have been met. The records submitted do not include a description of the condition of the 
enrollees power mobility device, the nature of the damage or wear which requires repair, or a rationale for 
why the repair is needed. Please submit records to the Plan to support this request. The enrollees tires and 
casters were replaced in March 2022 and the Plan states that the damage does not appear to be the result of 
normal wear and tear. Therefore, we decided that the Plan does not have to pre-approve power mobility device 
tire and caster replacement.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a visual field examination (92083) and a 
vision care office visit (99213) provided from May 11, 2022, to May 17, 2022. 
 
You asked the Plan to waive the copayment for a visual field examination (92083) and a vision care office visit 
(99213). You say that you paid your $50 copayment, and then had to go back a week later for the results. You 
also say they did not advise that there would be another charge. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
  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 $20 
copayment per day for outpatient diagnostic tests. Your contract with the Plan also clearly says that you must 
pay a $50 copayment for each outpatient visit for services to diagnose and/or treat a disease or condition of the 
eye.  
 
You have been asked to pay a $20 copayment for a visual field examination (92083). A visual field 
examination (92083) falls within the outpatient diagnostic tests benefit category. You have also been asked to 
pay a $50 copayment for a vision care office visit (99213). A vision care office visit falls under the outpatient 
visit for services to diagnose and/or treat a disease or condition of the eye 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 a visual field examination (92083) and a vision care office visit 
(99213) provided from May 11, 2022, to May 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0858, E1007, 
E2311, E2363, E2377, E2313, E1028, E2300, E2620, E0973, E0955, E1012, E0956, E2607, K0040). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says the requested power wheelchair cannot be 
approved as multiple power options (tilt + recline) are requested. The seat lift does not serve a medical purpose 
and cannot be covered. There is not a medical need to control multiple power options through the joystick. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 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 power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found criteria for a group 
wheelchair are use of a ventilator or intermittent catheterization or high risk for skin breakdown. The enrollee 
is not at high risk for skin breakdown. He can shift position, is not obese and uses a catheter. Seat elevation is 
not medically necessary per Medicare and the enrollee has functioning hands allowing for standard control of 
the wheelchair. The expandable controller is not 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 a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair and accessories (K0858, E1007, E2311, E2363, 
E2377, E2313, E1028, E2300, E2620, E0973, E0955, E1012, E0956, E2607, K0040).
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 disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 you were admitted to the hospital for sepsis and congestive heart failure. You are 
now medically stable with 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 the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit (99336) provided on January 17, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service was medically 
necessary. 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 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 rest home visit (99336) provided on January 17, 2022, by an 
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says the criteria for admission to an SNF are not met in this case. Based on your cognition it does not 
appear that you could receive skilled therapy services on a daily basis. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you have stabilized medically and are ready for discharge from the hospital. You 
are medically stable without any acute exacerbations of chronic medical problems. You do not have any 
parental medication; complex wound care or nutrition given via a feeding tube. You do not require skilled 
nursing and/or skilled therapy services on a daily basis. Although further rehab services would be appropriate 
to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of 
care than a skilled nursing facility, and your physical function is at or near baseline.  Admission to a SNF for 
inpatient skilled rehab services is not 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on June 30, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you had a CT scan on June 30, 2022 
and received a bill for $163.56. You say that you have CT scans done periodically, due to your current medical 
condition, and have never received a bill for them. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
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 $180 
copayment for each advanced imaging service (e.g., MRI, CT and PET scans, nuclear medicine, and stress 
tests).  
 
 
  You have been asked to pay $163.56, which is less than the standard $180 copayment for a CT scan. This 
item/service falls within Outpatient Hospital Services 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 a CT scan provided on June 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on July 7, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a specialist office visit. You say that this should have been covered. The Plan 
denied your request. The Plan says you must receive your care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 specialist office visit provided on July 7, 2022 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mastectomy for gynecomastia. 
 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 a mastectomy 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 records indicate that the enrollee 
has breast hypertrophy/gynecomastia. The records are insufficient to establish whether the criteria for coverage 
are met. The requested procedure is therefore 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 mastectomy for gynecomastia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve methotrexate 2.5MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says methotrexate tablet when used to treat rheumatoid arthritis is not one of the 
medications covered under the Medicare 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 methotrexate 2.5MG tablet.   
Benefits for the medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hydration services (96360) provided on May 6, 2022. 
 
You asked the Plan to pay for the hydration services. You say that the service was medically necessary. The 
Plan denied your request. The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that fluid used to administer the drug (s) is incidental 
hydration and is not separately payable. 
 
We looked at the file and Medicare rules. Code J2704 was approved. Fluids used to administer drugs are not 
separately payable. Based on this information, we decided that Medicare rules for coverage of the hydration 
services have not been met. Therefore, we decided that the Plan does not have to pay for hydration services 
(96360) provided on May 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75716 billed for date of service March 2, 
2022. 
 
You asked the Plan to pay for procedure code 75716. The Plan denied your request. The Plan says payment for 
code 75716 is bundled into payment for code 37225. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 75716 
is a column II code to column I code 37225. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 75716 billed for date of service March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) provided by 
an endodontist. 
 
You asked the Plan to pre-approve an evaluation. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says a comprehensive oral evaluation is not covered when received by 
an endodontist. 
 
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, the requested items or services are not 
among those covered under this benefit when received by an endodontist. Therefore, we decided that the Plan 
does not have to pre-approve a comprehensive oral evaluation (D0150) provided by an endodontist.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prochlorperazine 10MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the requested oral nausea medication prochlorperazine tablet is covered under the 
pharmacy benefit and is not covered under the Medicare medical benefit. 
 
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 medication. Our physician reviewer 
found the provider indicated that prochlorperazine is not full replacement for intravenous (IV) antiemetic 
therapy that would have been administered at the time of cancer chemotherapy treatment. The clinical progress 
notes from October 25, 2022, document that the enrollee has nausea and emesis daily and to take antiemetics 
every six (6) hours as needed. The review has determined that the medical records provided do not meet the 
requirements listed in the Medicare rule above. 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 medication have not been 
met. Therefore, we decided that the Plan does not have to pre-approve prochlorperazine 10MG tablet.  
 
Benefits for the medication 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0481 provided on March 29, 2022. 
 You asked the Plan to pay for the drug testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered were not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that definitive UDT is only covered for certain 
indications. 
 
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 drug testing. Our reviewer says that the 
documentation does not support that the services rendered were medically reasonable or necessary. Our 
physician reviewer found the enrollee's diagnosis is medication management of long term (current) drug 
therapy. The medical record sent by the provider shows presumptive screening test results which are consistent 
with prescription medications, dosing schedules, or history and expected results. There was sufficient 
information to manage the enrollee without definitive testing. Therefore, the enrollee did not meet LCD criteria 
for the drug testing provided. 
 
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 drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing coded G0481 provided on March 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs Heart Failure system. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the CardioMEMs HF System was 
approved by the Food and Drug Administration (FDA) in 2014. Subsequent follow-up studies remain 
encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, 
published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS. 
Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs Heart Failure system.