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 shoulder. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the doctor's notes should show the following: a doctor's order for the MRI, and shoulder 
pain that needs further assessment when plain x-ray results were normal. 
 
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. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found that in this case, the 
record indicates that the enrollee has shoulder pain. The record does not include an in-person visit or the 
existence of any red flag symptoms. The record does not include a physical examination or plain film results. 
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.  
 
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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the shoulder.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VIA Disc allograft intervertebral disc augmentation 
procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the research does not support this request for the enrollee's condition. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology.  Peer-reviewed literature stated cell 
therapy alone has not shown itself to provide sufficient intervention with regard to either efficacy or duration. 
Further studies are needed. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested VIA Disc allograft 
intervertebral disc augmentation procedure, in this case, is 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve VIA Disc allograft intervertebral disc augmentation procedure for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed. 
 
You asked the Plan to pre-approve a hospital bed. You say that this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the criteria for coverage of a hospital bed have not been 
satisfied. 
 
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary 
when at least one of the following criteria is met: 
 
1. The patient has a medical conditions which requires positioning of the body in ways not feasible with an 
ordinary bed; or 
 
2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate 
pain; or 
 
3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration.  Pillows or wedges must have 
been considered and ruled out; or 
 
4. The patient requires traction equipment, which can only be attached to a hospital bed. 
 
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 hospital bed. Our reviewer says that 
the requested hospital bed is not medically reasonable and necessary. Our physician reviewer found the 
documentation does not reveal that the enrollee is using this bed for a medical condition which requires 
positioning of the body in ways not feasible with an ordinary bed. The enrollee does not need positioning of the 
body in ways not feasible with an ordinary bed in order to alleviate pain, or that the patient requires the head of 
the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic 
pulmonary disease, or problems with aspiration, or that the enrollee requires traction equipment, which can 
only be attached to a hospital bed.  
 
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 hospital bed have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a hospital bed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on March 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 genetic testing provided on March 8, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Select MDx testing provided on June 22, 2021. 
 
You asked the Plan to pay for the Select MDx testing. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 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. 
 
No medical records were provided to support the validity of the services rendered. This means that the Select 
MDx test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the Select MDx 
testing provided on June 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0651) and a full arm 
segmental pneumatic appliance (E0668) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor and a full arm segmental pneumatic appliance to be 
provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan 
says there are in-network providers that are able to provide these services. Therefore, coverage criteria 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 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 a pneumatic compressor (E0651) and a full arm segmental pneumatic appliance (E0668) to be provided by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical connection for a power wheelchair (E2310) 
for the enrollee. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that based on the medical records provided there is no documentation that support that the electronic 
connection to control the power option of power tilt through a joystick at issue in this case meets all Medicare 
criteria. The provided occupational therapy records document that the enrollee has adequate upper extremity 
strength and function to manage her own oral medications thus indicating she has adequate upper extremity 
strength and function to operate the wheelchairs 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 the item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an electrical connection for a power wheelchair (E2310) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says based on 
Medicare guidelines, the long term acute care hospital services you are requesting do not meet the requirements 
for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with hypoxia, pulmonary edema 
in the setting of pulmonary fibrosis and complicated by pneumonia requiring high flow oxygen support, 
diuresis, steroids, and antibiotics. Recent notes describe the enrollee as still requiring high flow oxygen support 
and IV steroids. The enrollee appears to still be somewhat unstable but improving and should only require 
short-term additional acute care hospital services that can safely be administered at the current facility until 
more stable and appropriate for a lower level of care. The enrollee does not require services at the LTACH that 
are not already available at the current facility.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of mini dental implants 
represented by code D6013. 
 
You asked the Plan to pre-approve the surgical placement of mini dental implants. You say that  The Plan 
denied your request. The Plan says the services in dispute are not a covered benefit. 
 
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. Therefore, we decided that the Plan does not have to pre-approve the 
surgical placement of mini dental implants represented by code D6013.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has right hip pain, status 
post right total hip revision, and multiple co-comorbidities. The enrollee has recurrent infections requiring 
infectious disease work up, frequent monitoring, antibiotics, and frequent physical and occupational therapy. 
The Plan denied your request. The Plan says based on Medicare guidelines, the long term acute care hospital 
services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with an infected right hip 
prosthesis requiring irrigation, debridement, removal of hip components, placement of spacer, hip revision 
surgery, pain medications, wound care, and antibiotics. Recent notes describe the enrollee as needing ongoing 
IV antibiotics, physical and occupational therapy, and basic wound care but with stable vitals.  
 The enrollee appears to be more stable and improving and should only require short-term additional acute care 
hospital services that can safely be administered at the current facility until more appropriate for a lower level 
of care. The enrollee does not require services at the LTACH that are not already available at the current 
facility. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial observation care (99220) provided on April 23, 
2022. 
 
You asked the Plan to pay for the initial observation care. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this claim has not been billed with 
an appropriate diagnosis code.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that certain conditions have 
both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such 
conditions, it is required that the underlying condition be sequenced first followed by the manifestation. 
 
We looked at the file and Medicare rules. Specifically, this claim was billed with a primary/first-listed 
diagnosis code of R65.10 (Systemic inflammatory response syndrome (SIRS) of non-infectious origin without 
acute organ dysfunction). This is an instance where the underlying condition has not been sequenced first as 
required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 
initial observation care have not been met. Therefore, we decided that the Plan does not have to pay for the 
initial observation care (99220) provided on April 23, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on June 1, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
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 outpatient mental health services provided on June 
1, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on June 9, 2022. 
 
You asked the Plan to pay for eyeglasses. The Plan denied your request. The Plan says the vision benefit allows 
up to $200 every two years for eyeglasses. You exhausted the eyewear benefit on April 5, 2021. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that you have exhausted the eyewear benefit. Based 
on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, 
we decided that the Plan does not have to pay for eyeglasses provided on June 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 11 home health aide (HHA) visits (beyond 
the 10 approved visits). 
 
You asked the Plan to pre-approve the additional HHA visits. You say that the caregiver currently helping the 
enrollee is a home health aide. You also say the enrollee is getting physical therapy and speech therapy. The 
Plan denied your request. The Plan says the information provided does not support the need for a home health 
aide to make visits. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 additional HHA visits. Our reviewer 
says that the requested HHA visits do not meet Medicare criteria. Our physician reviewer found the requested 
HHA services are not shown to be required to assist in the treatment of an acute illness or injury. The enrollees care needs appear to be chronic, long-term and custodial. As such, HHA services are not medically necessary, 
reasonable or coverable. 
 
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 additional HHA visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional 11 home health aide (HHA) visits (beyond the 10 approved 
visits).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on August 9, 2021 and 
billed under code 83789-59. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says while codes G0480 and 80307 were paid, code 83789-59 is included in the payment for 
code 80307 and G0480; therefore, it cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, code 83789-59 cannot be separately 
paid and has created an error on the claim. Based on this information, we decided that Medicare rules for 
coverage of code this code have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services provided to the enrollee on August 9, 2021 and billed under code 83789-59.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical 
spine. 
 
You asked the Plan to pre-approve an MRI of the cervical spine. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 an MRI of the cervical spine. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found 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 an MRI of the cervical spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical spine.