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

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to medical appointments. The Plan denied your request. The Plan says you have utilized the maximum number 
of transportation trips allowed per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an audiology consultation to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve an audiology consultation with an out-of-network provider.. You say that 
you want to see this provider. The Plan denied your request. The Plan says the requested service is available in-
network. 
 
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 audiology consultation to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve the CT scan. You say that the enrollee has elevated ferritin and liver 
enzymes with abdominal pain. The Plan denied your request. The Plan says that the criteria for coverage have 
not been met. 
 
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 CT scan. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the enrollee presented with bilateral upper 
quadrant pain and fever and chills. Liver enzymes were elevated. While ultrasound is useful in cases of 
elevated liver enzymes, this patient presented with fever and chill and bilateral upper quadrate pain. CT of the 
abdomen and pelvis would be a good choice for imaging since the left upper quadrant is sometimes difficult to 
evaluate on ultrasound due to bowel gas. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the abdomen and pelvis.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour Next diabetic test strips. 
 
You asked the Plan to pre-approve test strips. You say that the requested items are a medical necessity for the 
enrollee. The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for test strips. Therefore, we decided that the Plan does not have to pre-approve Contour Next diabetic test 
strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
you need a power chair that will lift you up, so you are in an upright position to go into a standing position on 
your own. You also say that your wife is unable to assist with lifting you. The Plan denied your request. The 
Plan says although there are three requested power options (tilt, recline and elevating leg rests), there is not a 
medical need to control these power options through the joystick.  

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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found you are able to feed and groom yourself 
without hands on support. You have 3 out of 5 strength in your upper extremities. Our reviewer also found that 
you have adequate upper body strength to manage standard power drives. 
 
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 electronic connection, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman device (22612, 22840). 
 
You asked the Plan to pre-approve the Minuteman device. You say that this is medically necessary. The Plan 
denied your request. The Plan says the Medicare criteria for reasonable and necessary are not met because use 
of this device as a stand-alone procedure has not been shown to be safe and effective in long term studies. 
 
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 Minuteman device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found current evidence-based medical guidelines and peer-reviewed literature do not fully 
support the interspinous fusion device procedure over the gold standard of lumbar fusion. There is a lack of 
large-volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees 
medical condition. It is intended for use with bone graft material and is not intended for stand-alone use. In 
addition, fusion indications within guidelines/literature for (existing or potential intraoperative) instability have 
not been documented and/or met in this case. In addition, there are multiple alternate pain generators plausibly 
significantly contributing to the clinical condition that have not been fully documented as having been excluded 
and/or ruled out. No compelling rationale is presented, or extenuating circumstances noted to support the 
medical necessity of this request as an exception. 
 
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 Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Minuteman device (22612, 22840).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Sprint peripheral nerve stimulator (PNS) system 
(64555, C1778). 
 
You asked the Plan to pre-approve the Sprint PNS system. 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 Sprint PNS system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Sprint PNS device is experimental for combined back and leg pain. 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 Sprint PNS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Sprint peripheral nerve stimulator (PNS) system (64555, C1778).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that the right knee Orthovisc injection 
only provided the enrollee short term relief of their symptoms. The Plan denied your request. The Plan says the 
genicular nerve block 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 genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found the genicular 
nerve block is the subject of ongoing clinical trials and is considered an experimental and investigational 
procedure. 
 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient T2-L5 posterior lumbar interbody fusion with 
instrumentation. 
 
You asked the Plan to pre-approve inpatient T2-L5 posterior lumbar interbody fusion with instrumentation. 
You say that this is medically necessary. The Plan denied your request. The Plan says you do not meet criteria 
for coverage. 
 
The Plan follows Medicare rules. 
 
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 inpatient T2-L5 posterior lumbar 
interbody fusion with instrumentation. Our reviewer says that you do not meet criteria for coverage. Our 
physician reviewer found detailed documentation is not evident regarding dynamic flexion/extension 
radiographs demonstrating instability at the requested surgical levels. The magnetic resonance imaging is not 
evident regarding potential impending/inevitable temporary intra-operative instability. Additionally, detailed 
documentation regarding a trial and failure of recent, reasonable, comprehensive, less invasive conservative 
care measures is not evident. This includes injection therapy. Moreover, you are an everyday smoker. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient T2-L5 posterior lumbar interbody fusion with instrumentation have 
not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient T2-L5 posterior 
lumbar interbody fusion with instrumentation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Theraskin (Q4121). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not 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 service. Our physician reviewer 
found recent documentation, however, described the wound improving with current treatment efforts with a 
described increase in skin formation, reduced wound size, and granulation tissue. Therefore, without sufficient 
evidence of failure of current conservative treatments. The criteria for grafting have not been met.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Theraskin (Q4121).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an expandable controller (E2377) with harness (E2313) and 
electronic connection (E2311) for a power wheelchair. 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection. You say 
that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says 
that the requested items are not medically necessary.  
The Plan follows Medicare rules. Medicare rules say that an expandable controller is capable of 
accommodating additional functions. 
 
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 expandable controller with harness 
and electronic connection. Our reviewer says that the requested items are medically reasonable and necessary 
in this case. Our physician reviewer found that the enrollee cannot perform pressure relief independently due to 
upper extremity weakness and contractures. The complexity of the enrollee's seating and positioning needs 
necessitates a more complex Group 3 power wheelchair base. The expandable controller with harness and 
electronic connection are necessary to operate the Group 3 power wheelchair base and the three power options 
via a joystick. 
 
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 expandable controller with harness and electronic connection have been met. 
Therefore, we decided that the Plan has to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311) for a power wheelchair.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollee's condition they do not meet all of the requirements 
for admission.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for weakness and low back pain. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the medical records support a need for physical and/or occupational therapy, there 
is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prophylaxis - adult (D1110), periodic oral evaluation - 
established patient (D0120), bitewings - four radiographic images (D0274), and topical application of fluoride 
varnish (D1206) provided on April 26, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D1110, D0120, D0274 and D1206. You 
say that you were present when the representative verified the provider was in-network. The Plan denied your 
request. The Plan says the dental services were received from an out-of-network provider and are not covered 
by your supplemental 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. 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a prophylaxis - adult (D1110), periodic oral evaluation - established patient (D0120), bitewings - 
four radiographic images (D0274), and topical application of fluoride varnish (D1206) provided on April 26, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E23113), 
and electronic connector to 2 power options (E2311). 
 
You asked the Plan to pre-approve an expandable controller, harness, and electronic connector to 2 power 
options. 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 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 an expandable controller, harness, and 
electronic connector to 2 power options. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the enrollee does not require non-proportional input devices. The enrollee does not 
require a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an 
augmentative speech device or computer through the chair's drive control), or an attendant control. The 
documentation does not support that it is medically necessary to control the requested power options through 
the joystick (drive interface). The enrollee's upper extremity strength and functional ability, as evidenced on the 
wheelchair evaluation with ability to perform activities such as brush teeth, reach for objects in cabinets, 
control stove controls should be sufficient to control any power options through 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 an expandable controller, harness, and electronic connector to 2 power options 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller 
(E2377), harness (E23113), and electronic connector to 2 power options (E2311).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for approval. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee quit smoking more than 15 years ago. 
Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) 
scan for lung cancer screening.