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

 
We decided that the Plan does not have to pre-approve a solid seat insert (E0992) for a wheelchair 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 there is no separate payment for this. 
 
The Plan must follow Medicare rules. Medicare rules say that there is no separate payment for E0992.  
 
It it not appropriate to request E0992 separately in this case. 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 a solid seat insert (E0992) for a wheelchair for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve meals, nutritional counseling and dietitian visits. 
 
You asked the Plan to pre-approve meals, nutritional counseling and dietitian visits. You say that the services 
are medically necessary. The Plan denied your request. The Plan says the requested services is not a covered 
benefit. There is no qualifying chronic condition. 
 
The Plan contract covers a Healthy Pantry benefit.  
 
We looked at the file and the Plans rules. The file shows that you do not have a qualifying chronic condition. 
Based on this information, we decided that the Plans rules for coverage of meals, nutritional counseling and 
dietitian visits have not been met. Therefore, we decided that the Plan does not have to pre-approve meals, 
nutritional counseling and dietitian visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BRCA testing (81479) provided on December 9, 2021. 
 
You asked the Plan to pay for the BRCA testing. You say that you would like reconsideration because the 
genetic testing was not medically necessary. The Plan denied your request. The Plan says Medicare criteria for 
coverage of this testing have not been met. 
 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 pay for the BRCA testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not meet criteria for BRCA testing as they are over 51 years of age and only 
have one first degree relative who had a diagnosis of breast cancer in their 50s. 
 
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 BRCA testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the BRCA testing (81479) provided on December 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you do not have use of your right arm, and this 
is medically necessary and prescribed by your orthopedic doctor. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mental health services to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve mental health services. You say that you want to continue seeing your 
current mental health care provider. The Plan denied your request. The Plan says here are in-network providers 
in your area. 
 
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. Without supporting medical records, we 
cannot determine whether it is medically necessary for you to maintain continuity of care with an out-of-
network provider. 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 mental health services to be provided by an 
OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Computed Tomographic Angiography (CTA). 
 
You asked the Plan to pre-approve the CTA. You say that you would like reconsideration because the 
requested CTA is medically necessary. The Plan denied your request. The Plan says the enrollee's stress test 
was unremarkable. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CTA. Our reviewer says that 
clinical guidelines for the use of CTA have not been met based on review of the submitted clinical 
documentation. Radionuclide stress test recently performed was negative for ischemia and echocardiography 
showed normal left ventricular function. Our physician reviewer found at this time CTA imaging would not be 
considered medically reasonable 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 the CTA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Computed Tomographic Angiography (CTA).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that the requested radiofrequency ablation 
(RFA) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for the requested radiofrequency ablation (RFA). 
 
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 radiofrequency ablation. Our reviewer 
says that the enrollee does not meet criteria for the requested radiofrequency ablation (RFA). Our physician 
reviewer found the enrollee has chronic lower thoracic back pain. His Magnetic resonance imaging (MRI) 
shows severe spinal canal and forminal stenosis with a disc protrusion at T8-T9. There have been NO 
diagnostic medial branch blocks (MBBs) at T7-T9. The request is for RFA of T7-T9. The request does not 
meet the LCD criteria because there are no diagnostic MBBs. Therefore, the request is deemed 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiation physics consultation (77336) and an outpatient 
hospital clinic visit (G0463) provided on October 1, 2021, to October 28, 2021, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for a radiation physics consultation and an outpatient hospital clinic visit. You say 
that this provider provides care at the direction of the attending physician and, in turn, requests reimbursement 
for services rendered to your member. The Plan denied your request. The Plan says after review, it was 
determined that there are no records of a referral from the member's primary care physician to the Plan prior to 
services being rendered. 
 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 radiation physics consultation (77336) and an 
outpatient hospital clinic visit (G0463) provided on October 1, 2021, to October 28, 2021, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on June 16, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises. You say that a claim for a different date of service, 
February 18, 2021, for the same procedure code (97110) was partially paid. The Plan denied your request. The 
Plan says this provider is out-of-network with the Plan, and authorization was not obtained prior to the services 
being rendered. The Plan also says that regarding the appellant's statement that the Plan paid for similar 
services rendered on February 18, 2021, they reviewed their records and determined that was due to an 
administrative error. 
 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 therapeutic exercises (97110) provided on June 
16, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroilac joint arthrodesis for the enrollee. 
 
You asked the Plan to pre-approve the services. 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found detailed documentation is not evident regarding the results of the sacroiliac joint injections provided. 
Additionally, there is no documentation of imaging or radiographic evidence supporting a diagnosis of 
sacroiliitis. Multiple other plausible pain generators (including at the lumbosacral spine) are evident. There is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. Therefore, the enrollee does not meet the criteria for this request. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroilac joint arthrodesis for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for laparoscopy, surgical 
prostatectomy, retropubic radical, including nerve sparing and procedures laparoscopy sug: with bilateral total 
pelvic lymphadenectomy. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there was no clinical documentation provided indicating extenuating circumstances 
substantiating the medical necessity of this request as an exception to the criteria. 
 
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 out-of-network referral for laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing 
and procedures laparoscopy sug: with bilateral total pelvic lymphadenectomy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically reasonable for the 
enrollee's condition. The Plan denied your request. The Plan says the requested Intracept procedure is 
considered experimental/investigational. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group one power wheelchair (K0800). 
 
You asked the Plan to pre-approve a group one power wheelchair. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the documentation submitted indicates the beneficiary 
does have sufficient upper extremity function to self-propel an optimally configured manual wheelchair in the 
home to perform MRADLs during a typical day. 
 
The Plan follows Medicare rules. Medicare rules say that a PWC will not be covered if all the criteria listed in 
the Medicare Rules section is not met. 
 
The file shows that the beneficiary does have sufficient upper extremity function to self-propel an optimally-
configured manual wheelchair in the home to perform MRADLs during a typical day. 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 group one power wheelchair (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 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 A6533.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair cushion and repairs. 
 
You asked the Plan to pre-approve the services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the services is being requested for use in a long-term care facility. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair cushion and repairs.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64628, 64629). 
 
You asked the Plan to pre-approve the radiofrequency ablation procedure. You say that this service is 
medically necessary. The Plan denied your request. The Plan says this procedure is investigational and is non-
covered. 
 
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 radiofrequency ablation procedure. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the procedure requested is considered 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 radiofrequency ablation procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64628, 64629).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on November 12, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 was not a network provider with the Plan at the time of service. The Plan had network 
providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve 
the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we 
decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) 
provider on November 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair, bathtub rail, and incontinence supplies. 
 
You asked the Plan to pre-approve a shower chair, bathtub rail, and incontinence supplies. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs, bathtub rail, and incontinence 
supplies are not covered because they are not primarily medical in nature.  
 
While a shower chair, bathtub rail, and incontinence supplies may be appropriate in this case, neither the Plan 
nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a 
shower chair, bathtub rail, and incontinence supplies.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for non-emergency transportation. 
 
You asked the Plan to provide coverage for non-emergency transportation. You say that you need 
transportation to a dermatologist office. The Plan denied your request. The Plan says the non-emergency 
transportation is not a benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to provide coverage for are ambulance transport services to a doctors office. Therefore, we decided that the Plan does not have to provide coverage for non-emergency 
transportation.