Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the individual psychotherapy, 30 minutes with patient 
(90832) provided May 17, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that you have attached the medical records 
needed to process the claim. The Plan denied your request. The Plan says there is no documented contact with 
the attending/primary care physician. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the individual psychotherapy, 
30 minutes with patient (90832) provided May 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 30, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 76705 is bundled into 
payment for code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service April 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you had spinal surgery and have difficulty 
walking. The Plan denied your request. The Plan says you do not meet criteria for the requested device. 
 
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.  
 
The file shows that your condition can be improved by a walker. In addition, the documentation does not 
include the required evaluations for approval of the requested device. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
power scooter.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient mental health services. 
 
You asked the Plan to pre-approve the requested services. You say that you have established a repour with the 
enrollee. The Plan denied your request. The Plan says services are available with Medicare-certified providers. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve outpatient mental health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this item is medically necessary for 
managing your medical condition. The Plan denied your request. The Plan says the criteria for coverage have 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new power wheelchair and accessories. 
 
You asked the Plan to pre-approve a new power wheelchair and accessories. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested replacement item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a power wheelchair. The requested power wheelchair serves the same purpose as 
your current power wheelchair. Your current power wheelchair is less than five years old. The Plan has noted 
that at this point the repair cost is less than the replacement cost and is more cost effective to repair your 
currently wheelchair. Also, the requested accessories are not a covered benefit. The requested electronic 
connection between two power options is not covered as the documentation does not support a medical need to 
control the power options through the joystick. The power options can be controlled using their own switches. 
Therefore, we decided that the Plan does not have to pre-approve a new power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
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 role of genicular nerve blocks after 
total knee replacement is still being studied. It is considered experimental/ investigational at this time; 
therefore, the services are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a genicular nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider. 
 
You asked the Plan to pre-approve an office visit. You say that you have been unable to return home. You say 
that you have multiple pain related issues with your back and knee that require interventional treatment. The 
Plan denied your request. The Plan says there are multiple providers within the network that can provide the 
requested services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
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 documentation supports that IGRT 
is being used as routine practice and there are no exceptional circumstances with this patient necessitating the 
need for IGRT. The intent is palliative and it is not clear what benefit IGRT would afford. The use of IGRT 
with 3-D radiation is not the standard of care for routine use in palliative treatment of bone metastases. The 
services are 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 image-guided radiation therapy (IGRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an all lower extremity prosthesis, parts, supplies and 
services to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an all lower extremity prosthesis, parts, supplies and services. You say that 
this member has a heart condition requiring him to be able to walk as soon as possible. You also say that this 
member also has some issues with transportation, thus making it difficult to get the consistent prosthetic care 
he requires to promote his independence. You also say that you have been able to provide prosthetic services in 
his home, establishing him as a patient of yours. The Plan denied your request. The Plan says the request would 
have been approved if it was needed for one of the following reasons: there is an emergency, or there is no one 
in your network who can provide the equipment. The Plan also says that the records they were sent do not show 
that this is the case. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an all lower extremity prosthesis, parts, supplies and services 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 compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that this device is necessary for treating 
your medical condition. The Plan denied your request. The Plan says this item does not meet the statutory 
definition of a dressing and is not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH 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. 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. Our physician reviewer 
found the enrollee does not require services at the LTACH that are not available at the acute care hospital 
where she is currently receiving care. All medically necessary care is being provided in the current acute care 
setting. There are no services available at the LTACH that the enrollee requires that are not available at the 
health care setting being offered by the health plan. The health plan has approved ongoing care in the current 
acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for 
the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 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 long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional home physical therapy visits for the 
enrollee. 
 
You asked the Plan to pre-approve 4 additional home physical therapy visits. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that the enrollee and caregiver have been 
directed on a home exercise program. 
 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 4 additional home physical therapy 
visits. Our reviewer says that 4 additional home physical therapy visits are not medically reasonable and 
necessary. Records do not document any acute or unstable medical conditions or new injuries which would 
necessitate any further skilled physical therapy visits beyond what have already been approved. The enrollee 
has been educated on her disease process and home exercise program and she has caregivers available. Based 
on the available records the patient appears to have improved with therapy to the point of being contact guard 
to stand-by assist for ambulation of more than 300 feet with a rollator and contact guard assist for stairs and 
stand-by assist for transfers. After the physical therapy treatments already provided, records do not support that 
the complexity of the patient's conditions are such that the skills of a professional therapist are required to 
achieve further improvement in the patient's symptoms or functional status. Further utilization of the home 
exercise program appears appropriate at this point. No medical notes from the enrollee's treating physician are 
provided documenting an order or need for additional skilled physical therapy services beyond what have 
already been provided. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for 4 additional home physical therapy visits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4 additional home physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 4 additional home physical therapy visits for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of any joint of the 
lower extremity (73721) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the MRI. You say that you do not want the imaging rendered by an in-
network provider. The Plan denied your request. The Plan says Medicare only requires your group to provide 
exceptions for care that cannot be provided in their network. The Plan also says that a network provider can 
care for your medical problem. 
 
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 magnetic resonance imaging (MRI) of any joint of the lower extremity (73721) to be provided by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921) for all 4 quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied 
your request. The Plan says gingival irrigation is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested gingival irrigation is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gingival irrigation (D4921) for all 4 quadrants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that you would like this device covered for 
your medical condition. The Plan denied your request. The Plan says Medicare does not cover ventilators used 
in the requested way and your needs could be met by a bilevel positive airway pressure (BiPAP) device instead. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilators used to provide continuous or bilevel 
positive airway pressure (PAP) therapy, regardless of the underlying medical condition, are not covered. 
 
 
 
 
 
 
 
 
 
 
  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-
approve a portable ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve AttraX Putty spine fusion material. 
 
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 enrollee is being treated for other 
forms of scoliosis, flatback syndrome, lumbar radiculopathy, and lumbar spinal stenosis with neurogenic 
claudication. There was an approval for a staged anterior, lateral interbody fusion followed by stage II posterior 
spinal fusion. There is limited published, large-scale, long-term peer-reviewed literature that shows the AttraX 
Putty to be an effective and/or safe treatment for the noted pathology. The services are 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 AttraX Putty spine fusion material.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473), intravenous 
sedation (D9243), and osseous surgery (D4260). 
 
You asked the Plan to pre-approve the dental services. You say that you want to save your teeth as much as 
possible. The Plan denied your request. The Plan says the removal of torus mandibularis (D7473), intravenous 
sedation (D9243), and osseous surgery (D4260) are not covered by your routine dental benefits. 
 
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 
removal of torus mandibularis (D7473), intravenous sedation (D9243), and osseous surgery (D4260).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over the counter COVID-19 tests received from August 7, 
2021, to August 27, 2021. 
 
You asked the Plan to pay for the tests. You say that this should be paid for. The Plan denied your request. The 
Plan says this was not covered until April 4, 2022. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the tests is 
an OTC item. Medicare started to offer a benefit for these tests, but it was implemented after the date of service 
in this case. Therefore, we decided that the Plan does not have to pay for over the counter COVID-19 tests 
received from August 7, 2021, to August 27, 2021.