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

 
We decided that the Plan does not have to pre-approve addition, endoskeletal knee-shin system, single axis, 
fluid swing and stance phase control (L5828) addition, endoskeletal, knee-shin system, stance flexion feature, 
adjustable (L5845) addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability (L5848) addition to lower extremity prosthesis, endoskeletal knee-shin system, 
microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type (L5856). 
 
You asked the Plan to pre-approve the microprocessor knee. You say that you are appealing the denial of a 
prior approval request for the microprocessor knee and foot on the right above knee prosthesis The Plan denied 
your request. The Plan says the records do not support why a microprocessor knee is medically necessary and 
why a mechanical K3 knee will not meet the enrollee's needs. 
 
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 microprocessor knee. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a microprocessor knee is only covered when an enrollee meets all of the criteria in 
LCD L33787, including K3 functional level only. The documentation does not support that the enrollee is 
functioning at a K3 level.  
 
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 microprocessor knee have not been met. Therefore, we decided that the Plan 
does not have to pre-approve addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase 
control (L5828) addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845) addition to 
endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability (L5848) 
addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing 
and stance phase, includes electronic sensor(s), any type (L5856).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that these services were medically necessary. The 
Plan denied your request. The Plan says prior authorization was not obtained for this out-of-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 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 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollees condition they do not meet all the requirements. 
 
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 the enrollee's nursing medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 The enrollee was admitted for sepsis, COVID-19 infection, sickle cell crisis, and anemia. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the enrollee has a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided June 24, 2022. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you believe you should not have a 
copayment because you had polyps at least three times. 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 $100 
copayment for Outpatient hospital services.  
 
You have been asked to pay a $100 copayment for a colonoscopy. This item/service falls within the 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 colonoscopy 
provided June 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on August 27, 2021. 
 
You asked the Plan to pay for the testing services. You say that the claim denied incorrectly. The Plan denied 
your request. The Plan says the rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim information does not show that the testing was billed with a 
modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing 
services provided on August 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee's ability to breathe is severely 
impaired. You say that the clinical documentation provided supports the need for the requested home 
ventilator. The Plan denied your request. The Plan says the use of a portable ventilator is not medically 
necessary because it would be used to deliver ventilatory support via settings that could be equally provided by 
a bilevel positive airway pressure (BiPAP) with average volume assured pressure support (AVAPS) settings. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary. The enrollee has chronic obstructive pulmonary disease (COPD) and is on home oxygen (O2.)  Pulmonary Function Tests (PFTs) in 2019 showed forced expiratory volume (FEV1) 61% predicted.  
There is no documentation of chronic carbon dioxide (CO2) retention with arterial blood gas (ABG) done 
while stable as an outpatient. Therefore, the enrollee does not meet criteria for a positive airway pressure (PAP) 
device for ventilatory support. If chronic CO2 retention were present, BiPAP with AVAPS would be the 
appropriate treatment. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require intensive rehabilitation services. The enrollee does not 
require frequent physiatry oversight. Post-acute care needs may reasonably be met without an IRF admission. 
 
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: Favorable

 
We decided that the Plan has to pay for an office visit provided on February 7, 2022. 
 
You asked the Plan to pay for office visit. You say that the enrollee was visiting family and needed care due to 
COVID-19 symptoms. The Plan denied your request. The Plan says that this provider is out-of-network with 
the Plan and authorization was not obtained. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
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 office visit. Our reviewer says that this visit 
meets criteria for payment. Our physician reviewer found the enrollee could not have foreseen requiring this 
service prior to leaving the Plan's service area. The enrollee was visiting Georgia and was evaluated for sore 
throat and exposure to COVID-19. The enrollee was evaluated with a history and physical examination and 
laboratory studies were performed. Antibiotic therapy was prescribed. The care provided was medically 
necessary. It would not have been medically reasonable to delay the services until the enrollee returned to the 
Plan's service area. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of office visit have been met. Therefore, we decided that the Plan has to pay for an 
office visit provided on February 7, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic analysis of implanted neurostimulator 
pulse generator/transmitter (95971), a generator, neurostimulator (implantable), high frequency, with 
rechargeable battery and charging system (C1822), an implantable neurostimulator electrode (L8680) and a 
percutaneous implantation of neurostimulator electrode array, epidural (63650). 
 
You asked the Plan to pre-approve spinal cord electrical stimulator. You say that your pain has gotten worse, 
and you feel that the electric stimulator will help. The Plan denied your request. The Plan says your request is 
not medically necessary because your records show you do not have a condition for which this treatment is 
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 spinal cord electrical stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have lumbar post-laminectomy syndrome. An MRI of your lumbar 
spine does not show a surgical issue. There is no documentation of a psychological evaluation. This is required 
and not yet documented. 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal cord electrical stimulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an electronic analysis of implanted neurostimulator pulse 
generator/transmitter (95971), a generator, neurostimulator (implantable), high frequency, with rechargeable 
battery and charging system (C1822), an implantable neurostimulator electrode (L8680) and a percutaneous 
implantation of neurostimulator electrode array, epidural (63650).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral examination provided on July 13, 2022. 
 
You asked the Plan to pre-approve the dental services. You say that you were offered an earlier appointment 
due to a cancellation. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 22, 2022. 
Therefore, we decided that the Plan does not have to pre-approve an oral examination provided on July 13, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for office visits provided on March 25, 2022, 
and June 22, 2022. 
 
You asked the Plan to waive the deductible for office visits. You say that you disagree with the copayment 
amounts and would like the Plan to reconsider payments. 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 $1,000 
deductible for out-of-network Medicare-covered services.  
 
You have been asked to pay a total deductible of $213.60 for office visits. This total is applied to your $1,000 
deductible, which needs to be met before the Plan will pay their share for your covered medical services. This 
item/service falls within the Physician/Practitioner 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 deductible for office visits provided on March 25, 2022, to June 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (CPT code 20939). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of spinal 
fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found bone marrow aspirate remains experimental. More research is needed to show safety and 
efficacy. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the bone marrow aspirate (CPT code 20939).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extractions, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), alveoloplasty in 
conjunction with extractions - four or more teeth or tooth spaces, per quadrant (D7310), deep sedation/general 
anesthesia  first 15 minutes (D9222) and deep sedation/general anesthesia  each subsequent 15 minute 
increment (D9223). 
 
You asked the Plan to pre-approve tooth extractions, alveoloplasty, and deep sedation/general anesthesia. You 
say that these services were medically necessary. The Plan denied your request. The Plan says tooth extractions 
and alveoloplasty are not covered under the enrollees benefits. The anesthesia is not covered because the 
primary procedures are not covered. 
 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, extractions and alveoloplasty are not 
among those covered under this benefit. Since the enrollee will not have any covered procedures, the anesthesia 
is also not covered Therefore, we decided that the Plan does not have to pre-approve the extractions, erupted 
tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if 
indicated (D7210), alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per 
quadrant (D7310), deep sedation/general anesthesia  first 15 minutes (D9222) and deep sedation/general 
anesthesia  each subsequent 15 minute increment (D9223).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies (A0422) 
provided on May 20, 2021. 
 
You asked the Plan to pay for the ambulance oxygen and oxygen supplies. You say that you would like this 
claim to be reviewed and processed towards payment. The Plan denied your request. The Plan says this service 
is not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that payment for items and services, such as oxygen, 
is included in the fee schedule payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance oxygen and oxygen supplies have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance oxygen and oxygen supplies (A0422) provided on May 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need the inpatient rehabilitation facility 
admission because you need speech therapy and had a bladder infection that left you very weak. The Plan 
denied your request. The Plan says based on Medicare guidelines the services you are requesting do not meet 
the requirements for approval. 
 
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 do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted 
with a urinary tract infection and urinary retention. Medical problems are stable. There are no complex nursing 
or rehabilitation needs. While you have a need for physical or occupational therapy, there is no documentation 
of a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.