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

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says all of the services needed are available at the inpatient rehabilitation facility (IRF). 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found you have not 
met all of the intensive rehabilitation goals documentation. The evaluating therapists document a requirement 
for intensive therapy. Although you are benefiting from daily skilled nursing and therapy services in an 
inpatient rehabilitation facility (IRF), intensive rehab would not be available in a skilled nursing facility from a 
practical standpoint. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) with appliance. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you are requesting payment for 
use of this device. The Plan denied your request. The Plan says the denial of payment for these items is correct. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) with appliance.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on October 27, 2021. 
 
You asked the Plan to pay for the drug testing services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the drug testing services provided on October 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the photochromatic tint (V2744), tint (V2745), 
polycarbonate lens (V2784), lenses (V2100), anti-reflective coating (V2750), UV lens (V2755), and frames 
(V2020) provided from February 25, 2021, to March 1, 2022. 
 
You asked the Plan to pay more for the photochromatic tint, anti-reflective coating, polycarbonate lens, and 
lens. You say that over the last few years you have purchased five different pairs of glasses all with different 
prescription lenses for different needs. The Plan denied your request. The Plan says the maximum amount 
covered by your plan for these services has been paid. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $270 for non-Medicare covered eyewear during the 2021 Plan year, and the 
Plan covers up to $240 for non-Medicare covered eyewear during the 2022 Plan year. 
 
We looked at the file and the Plan's rules. The record shows that you exhausted your eyewear allowance for the 
2021 plan year on February 25, 2021, and you exhausted your eyewear allowance for the 2022 plan year on 
January 19, 2022. Based on this information, we decided that the Plan's rules for coverage of the 
photochromatic tint, anti-reflective coating, polycarbonate lens, and lens have not been met. Therefore, we 
decided that the Plan does not have to pay more for the photochromatic tint (V2744), tint (V2745), 
polycarbonate lens (V2784), lenses (V2100), anti-reflective coating (V2750), UV lens (V2755), and frames 
(V2020) provided from February 25, 2021, to March 1, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services provided from  
November 7, 2021, through November 8, 2021. 
 
You asked the Plan to pay for emergency department services. The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
 
  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for emergency department services provided from  
November 7, 2021, through November 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 13 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that you feel the enrollee would greatly benefit 
from continued supervised PT for continued skilled interventions to improve safety and mobility. The Plan 
denied your request. The Plan says per the submitted clinicals, you need occasional help with dressing yourself, 
your left upper extremity range of motion is improved, your lower extremity strength is improved, you can now 
more easily sit and stand, and you are able to do more on your own. The Plan also says that you can continue 
your home exercise program without the guidance of a licensed therapist. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. Our physician reviewer also found that the additional therapy services are not an appropriate 
duration and frequency for treatment of the enrollees medical condition and therefore are not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 13 additional physical therapy (PT) visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to approve 12 additional physical therapy (PT) visits. 
 
You asked the Plan to 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. The rules say that Medicare pays for medically necessary outpatient 
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 approve these services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has had prior therapy for a broken hip in 2020. The 
records do not reveal that her functional level requires the unique skills of a professional therapist to safely and 
effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or 
by or under the supervision of a therapist. The services are not part of a maintenance program and the 
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain her current condition or to prevent or slow further deterioration. The additional 
PT services are therefore not reasonable or medically necessary at this time. 
 
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 approve 12 additional physical therapy (PT) visits.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 5, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 1, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services 
provided on January 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve phrenic nerve stimulation with the Remede system. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show a diagnosis of a spinal cord injury. 
 
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 the records do not show a diagnosis of spinal cord injury or brainstem lesion. 
 
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 phrenic nerve stimulation with the Remede system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gastroenterology services provided on June 8, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON gastroenterology services. You say that you have provided medical 
records to support payment of this claim. The Plan denied your request. The Plan says unauthorized, non-plan 
care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 gastroenterology services provided on June 8, 2021 by an out-of-
network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve facet joint radiofrequency ablation. You say that the requested thermal facet 
joint radiofrequency ablation is medically necessary. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for the requested thermal facet joint radiofrequency ablation. 
 
 
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 facet joint radiofrequency ablation. Our 
reviewer says that the enrollee does not meet criteria for the requested thermal facet joint radiofrequency 
ablation. Our physician reviewer found according to Medicare criteria, repeat thermal facet joint RFA at the 
same anatomic site is considered medically reasonable and necessary provided the patient had a minimum of 
consistent 50% improvement in pain for at least six (6) months or at least 50% consistent improvement in the 
ability to perform previously painful movements and activities of daily living as compared to baseline 
measurement using the same scale. 
 The enrollee is with chronic neck pain due to cervical spondylosis.  The enrollee failed to respond to 
conservative treatment including physical therapy.  The enrollee is status post left C4-5 and C5-6 RFA 
performed November 16, 2021; the records indicate that the enrollee initially experienced 70% pain relief. 
However, 5 months later, on April 13, 2022, the enrollee had constant neck pain at that time, described as 8/10, 
and radiating down the left shoulder. Two months later, June 8, 2022, the enrollee had 7/10 pain. Magnetic 
resonance imaging (MRI) of the neck from December 30, 2020, showed "broad based" disc herniations at C2-3 
and C3-4. 
 
The requested procedure is not medically reasonable or necessary according to the coverage criteria established 
in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint radiofrequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve facet joint radiofrequency ablation (RFA).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the thorax (71271). 
 
You asked the Plan to pre-approve a CT of the thorax. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that a lung cancer screening counseling and shared 
decision-making visit, and for appropriate beneficiaries, annual screening for lung cancer with Low Dose 
Computed Tomography (LDCT), as an additional preventive service benefit under the Medicare program, only 
if all of the following eligibility criteria are met. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT of the thorax. Our reviewer says 
that the criteria for coverage are not met. Our physician reviewer found the request for a 1 year follow up CT 
for pulmonary nodules is reasonable, however, the requested LDCT code 71271 is not appropriate for such 
follow up. 
 
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 CT of the thorax have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomography (CT) of the thorax (71271).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan (93971) provided on December 16, 2021. 
 
You asked the Plan to pay for the duplex scan (93971). You say that the attached medical records should be 
reviewed, and the claim reconsidered. The Plan denied your request. The Plan says an appropriate modifier was 
not billed with this code edit. 
  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 93971 
is a column II code to column I code 93970. 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 the duplex scan (93971) provided on December 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on January 26, 2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that the patient was an inpatient at an 
assisted living facility and the services were provided in good faith. The Plan denied your request. The Plan says the 
services were not urgent or emergent and an authorization was not obtained prior to the services being rendered 
and the provider is not participating with the member's Plan. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for domiciliary or rest home visit provided on January 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Metronidazol gel. 
 
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 self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Metronidazol gel.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis provided on December 2, 2020. 
 
You asked the Plan to pay for lumbar-sacral orthosis. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the denial of payment for this item is correct, because the 
documentation submitted does not include a physician's order, itemized shipping invoice, or proof of delivery 
to support the code billed. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a lumbar-sacral orthosis provided on 
December 2, 2020. have been met. Specifically, the record does not include proof of delivery for the item billed 
on this claim. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis provided on 
December 2, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled rehabilitation services. 
 
You asked the Plan to pre-approve skilled rehabilitation services. The Plan denied your request. The Plan says 
there is no documentation that your condition will improve materially in a reasonable and generally predictable 
period of time. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve skilled rehabilitation services. Our 
reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do 
not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, 
and judgment of a skilled professional therapist. Our reviewer also found that you do not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skilled rehabilitation services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skilled rehabilitation services.