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

 
We decided that the Plan does not have to pre-approve a CT scan with cardiac scoring. 
 
You asked the Plan to pre-approve a CT scan with cardiac scoring. You say that the enrollee has an elevated 
blood pressure with diagnosis of hypertension and marked hyperlipidemia. The Plan denied your request. The 
Plan says a CT scan with cardiac scoring is not medically necessary. 
 
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 a CT scan with cardiac scoring. Our 
reviewer says that a CT scan with cardiac scoring is not medically necessary. Our physician reviewer found 
that the enrollee is at a high risk of atherosclerotic cardiovascular disease. While there is an indication of 
moderate to high intensity statins a CT scan with calcium scoring is 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 a CT scan with cardiac scoring have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a CT scan with cardiac scoring.
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 the enrollee would benefit from an 
admission to an LTACH to regain maximum/prior level of functioning and continue multidisciplinary approach 
to care. The Plan denied your request. The Plan says the LTACH services requested do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The health plan has approved ongoing care in the current 
acute care setting. Our reviewer also found that 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on February 22, 2023.  
You asked the Plan to pay for the refraction. You say that you were unaware that only a certain kind of eye 
doctor was covered. The Plan denied your request. The Plan says the service was not a covered benefit. 
 
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 this service when performed as a part of a routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was performed due to Plaquenil 
monitoring which is considered medical in nature. Based on this information, we decided that the Plan's rules 
for coverage of the refraction have not been met. Therefore, we decided that the Plan does not have to pay for 
the refraction provided on February 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you are requesting reconsideration due to 
medical necessity. The Plan denied your request. The Plan says the request for a non-invasive ventilator (NIV) 
is not medically necessary because the documentation does not support that this device meets but does not 
exceed the enrollee's need. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
with auto-EPAP (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. As stated 
in the Local Coverage Determination (L33800): "Claims for ventilators used to provide CPAP or bi-level 
CPAP therapy for conditions described in this RAD policy will be denied as not reasonable and necessary." 
The LCD requires: "There must be enough detailed information in the medical record to justify the treatment 
selected." Provided records in this case do not provide adequate detailed information to meet Medicare criteria 
for coverage of a ventilator as opposed to a BiPAP device with AVAPS and a back-up rate. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on January 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on January 19, 2023.
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. You say that the medical records provided support the need for 
IRF admission.  The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services 
requested do not meet the requirements for approval. 
 
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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, advanced life support and ground 
mileage provided on January 24, 2022. 
 
You asked the Plan to pay for the ambulance service, advanced life support and ground mileage. You say that 
you submitted the claim as soon as the insurance information became available to you. The Plan denied your 
request. The Plan says the claim was untimely, and the submission did not meet the exception criteria 
guidelines. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
 
 The record shows that a claim for the ambulance service, advanced life support and ground mileage was not 
filed until February 2, 2023. This means that more than one calendar year from the date of service had passed 
before a claim was filed. Therefore, we decided that the Plan does not have to pay for ambulance service, 
advanced life support and ground mileage provided on January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a knee orthosis (L1845). 
 
You asked the Plan to pre-approve a knee orthosis. You say that the enrollee has not had a recent injury/surgery 
to the knee, but is unable to walk safely without a brace. You also say that the brace would be used to create 
stability during activities of daily living and ambulation. The Plan denied your request. The Plan says that this 
request is not medically necessary because the records show the enrollee does not have knee instability, or a 
recent knee injury or surgery. 
 
The Plan follows Medicare rules. Medicare rules say that a knee orthosis (L1845) is covered if the beneficiary 
has had recent injury to or a surgical procedure on the knee(s) and/or for a beneficiary who is ambulatory and 
has knee instability due to a specified condition. 
 
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 knee orthosis. Our reviewer says that 
the enrollee meets the coverage criteria for a knee orthosis. Our physician reviewer found the enrollee is 
ambulatory. Knee instability is documented on objective examination. Our reviewer found that this is related to 
the relatively severe combination of loading-unloading on a severely arthritic knee with severe valgus 
deformity. Our physician reviewer also found that the knee instability is reasonably documented by 
examination of the beneficiary and objective description of joint laxity, again based on the combination of the 
preceding history and clinical examination. 
 
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 knee orthosis have been met. Therefore, we decided that the Plan has to pre-
approve a knee orthosis (L1845).  
 
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 an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is in the hospital and not getting the 
rehabilitation care they need. You also say the enrollee's condition is worsening and IRF services will help the 
enrollee get the care they need to be able to go home. The Plan denied your request. The Plan says based on the 
medical records received, the enrollee's condition does not meet Medicare guidelines for services in an IRF.  
 
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy 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 an IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve white glass with metal cap for bridge for teeth 12 and 15 
(D6751) and false tooth for bridge for teeth 13 and 14 (D6240). 
 
You asked the Plan to pre-approve white glass with metal cap and false tooth for bridge. You say that this is 
medically necessary for the enrollee. The Plan denied your request. The Plan says bridges are covered to 
replace only 1 upper anterior tooth or only 2 adjacent lower anterior teeth. There cannot be any missing 
posterior teeth in the arch. To approve a bridge, you must be missing only one upper front tooth or only two 
lower front teeth. The two lower front teeth must be next to each other. You also cannot be missing any of your 
back teeth. With bilateral missing teeth, and poor periodontal condition a removable partial denture would be 
the most conservative and efficient method of tooth replacement. 
 
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 Plan covers white glass with metal cap and false tooth for bridge when the services are medically necessary and reasonable.  
 
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 white glass with metal cap and false 
tooth for bridge. Our reviewer says that the service is not medically necessary. Our physician reviewer found a 
review of the documentation indicates that there is a fixed bridge replacing missing tooth #14 that is defective. 
An abutment retainer (tooth #13) is fractured and non-restorable. Tooth #3 is also missing. Fixed bridges may 
be considered for coverage when replacing a single maxillary anterior tooth or two adjacent mandibular 
anterior teeth. In this case there are 3 missing maxillary posterior teeth (#'s 3, 13 and 14) which can be replaced 
by an alternative prosthesis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of white glass with metal cap and false tooth for bridge have not been met. 
Therefore, we decided that the Plan does not have to pre-approve white glass with metal cap for bridge for 
teeth 12 and 15 (D6751) and false tooth for bridge for teeth 13 and 14 (D6240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a back up battery (E1399). 
 
You asked the Plan to pre-approve a back up battery. You say that you need this item in case the energy is out. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal is one of convenience. Therefore, we decided that the Plan does not have to pre-
approve a back up battery (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214-25 billed for date of service February 
22, 2023. 
 
You asked the Plan to pay for the billed services. You say that the claim was submitted with a modifier. The 
Plan denied your request. The Plan says the service is included in payment for major surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We find that CPT code 99214-25 was billed with major surgical procedure code 15260. CPT code 99214 was 
not billed with an appropriate modifier suitable for separate payment. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99214-25 billed for date of service February 22, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Piqray (C9399). 
 
You asked the Plan to pre-approve Piqray. You say that you would like Piqray to be approved for the enrollee 
to provide them with personalized, clinically rational treatment. The Plan denied your request. The Plan says 
the medication is not covered as a medical benefit under the Plan. 
 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 Piqray (C9399).  
 
Benefits for Piqray 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology (cutaneous melanoma), mRNA, gene 
expression profiling by real-time RT-PCR of 31 genes (81529), BRAF (B-Raf proto-oncogene, 
serine/threonine kinase) (eg, colon cancer, melanoma), gene analysis (81210) and NRAS (neuroblastoma RAS 
viral oncogene homolog), gene analysis (81311). 
 
You asked the Plan to pre-approve genetic testing. You say that the enrollee had a shave biopsy of the right 
posterior shoulder on April 28, 2022, having a confirmed malignant melanoma diagnosis with a pathologic 
stage of T1b. The Plan denied your request. The Plan says records do not show a presumed risk for a positive 
Sentinel Lymph Node Biopsy (SLNB) based on clinical, histological, or other information is greater than 5%. 
 
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 genetic 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 approval of the requested testing based on LCD 37748. 
The testing is 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 genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve oncology (cutaneous melanoma), mRNA, gene expression profiling by real-time RT-PCR 
of 31 genes (81529), BRAF (B-Raf proto-oncogene, serine/threonine kinase) (eg, colon cancer, melanoma), 
gene analysis (81210) and NRAS (neuroblastoma RAS viral oncogene homolog), gene analysis (81311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a seat lift mechanism that is electrically operated (E0627). 
 
You asked the Plan to pay for a seat lift mechanism that is electrically operated . You say that the item is 
medically necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 pay for a seat lift mechanism that is electrically 
operated. Our reviewer says that the enrollee does not need this medical item. Our physician reviewer found the enrollee is non ambulatory. 
 
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 seat lift mechanism that is electrically operated have not been met. Therefore, 
we decided that the Plan does not have to pay for a seat lift mechanism that is electrically operated (E0627).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Shingrix (shingles) vaccine (90750) provided on January 
25, 2023. 
 
You asked the Plan to pay for the vaccine. You say that you did not receive the vaccine at the doctor's office 
after being told how much it would cost you. You say that you had it done at a pharmacy. You say that you 
received a bill for $312. You also say that you should not have to pay this as you never received this service. 
The Plan denied your request. The Plan says this vaccine is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine. Additionally, the provided records indicate that the vaccine was administered in the doctor's office. While this 
vaccine is eligible for coverage under Medicare Part D, payment must be made in full and reimbursement 
requested. Therefore, we decided that the Plan does not have to pay for the Shingrix (shingles) vaccine (90750) 
provided on January 25, 2023.  
 
Benefits for the vaccine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.