Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve routine transportation. You say that you are unable to drive due to your 
injury. The Plan denied your request. The Plan says routine transportation beyond 12 one-way trips per year is 
not covered by the Plan. 
 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 12 trips per year.  
 
We looked at your request, the records in the case file, and the rules. At the time the Plan made its decision, 
you had used 9 of the 12 covered one-way trips. Based on this information, we decided that after you receive 3 
more covered one-way trips you will have exhausted the Plan maximum benefit for coverage of routine 
transportation. Additional routine transportation is not covered by the Plans benefits. Therefore, we decided 
that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan of the thoracic spine. 
 
You asked the Plan to pre-approve a CT scan of the thoracic spine. You say that your physician has requested a 
CT scan due to you having pain on your amputated leg. The Plan denied your request. The Plan says that a CT 
scan of the thoracic spine 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 of the thoracic spine. Our 
reviewer says that a CT scan of the thoracic spine is medically necessary. Our physician reviewer found that 
the thoracic CT scan is necessary to assess the placement of the spinal cord stimulators (SCS) leads. Therefore, 
the requested scan if medically reasonable and 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 of the thoracic spine have been met. Therefore, we decided that the 
Plan has to pre-approve a CT scan of the thoracic spine.  
 
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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says 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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You require treatment by 
multiple therapies, including physical and occupational therapy, but this can be provided in a lower level of 
care. Although you could tolerate the therapy in the IRF, the complexity of your condition doesnt require an 
IRF stay and care can be provided in a lower level.  
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs for a manual wheelchair. 
 
You asked the Plan to pre-approve manual wheelchair repair. You say that it is most cost-effective to proceed 
with repairs rather than replacing the chair. The Plan denied your request. The Plan says the total cost of repairs 
to this wheelchair exceeds the estimated cost of replacement; therefore, repairs are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that repairs to equipment are not covered if the 
expense for repairs exceeds the estimated expense of purchasing or renting another item of equipment for the 
remaining period of medical need.  
 
We looked at the file and Medicare rules. The total cost of the current wheelchair with the requested repairs is 
$6,495.09. The Plan has estimated that the cost of a replacement wheelchair is $3,53.01. Therefore, the cost of 
repairs exceeds the cost of a replacement wheelchair. Based on this information, we decided that Medicare 
rules for coverage of manual wheelchair repair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repairs for a manual wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial. The Plan denied your 
request. The Plan says that the enrollee's care needs can be met at a lower level of care.  
 
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. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 64415, defined as injection(s), anesthetic agent(s) 
and/or steroid; brachial plexus, including imaging guidance, when performed, billed on date of service July 3, 
2023. 
 You asked the Plan to pay for 64415. You say that 64415 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 64415 is denied because the diagnosis billed does 
not correlate with the modifier billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must comply with ICD-10-CM coding 
guidelines. The rules also say that codes for unspecified side should rarely be used, such as when the 
documentation in the record is insufficient to determine the affected side. 
 
We looked at the file and Medicare rules. We confirmed that code 64415 was billed with modifier -LT, 
indicating the injection services were performed on the enrollee's left side. Documentation in the record also 
supports that a left interscalene nerve block was placed. We also confirmed that the claim in this case was 
billed with diagnosis code S42.309A, defined as unspecified fracture of shaft of humerus, unspecified arm, 
initial encounter for closed fracture. Per ICD-10-CM coding guidelines, diagnosis codes describing an 
unspecified side should only be used when documentation in the record is not sufficient to determine the 
affected side. Based on this information, we decided that Medicare rules for coverage of 64415 have not been 
met. Therefore, we decided that the Plan does not have to pay for code 64415, defined as injection(s), 
anesthetic agent(s) and/or steroid; brachial plexus, including imaging guidance, when performed, billed on date 
of service July 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high dose rate electronic brachytherapy, skin surface 
application, per fraction, includes basic dosimetry, when performed (0394T), and therapeutic radiology 
simulation (77280, 77290). 
 
You asked the Plan to pre-approve high dose rate electronic brachytherapy, skin surface application, per 
fraction, includes basic dosimetry, when performed, and therapeutic radiology simulation. 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 high dose rate electronic brachytherapy, 
skin surface application, per fraction, includes basic dosimetry, when performed, and therapeutic radiology 
simulation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of high dose rate electronic brachytherapy, skin surface application, per fraction, 
includes basic dosimetry, when performed, and therapeutic radiology simulation have not been met. Therefore, 
we decided that the Plan does not have to pre-approve high dose rate electronic brachytherapy, skin surface 
application, per fraction, includes basic dosimetry, when performed (0394T), and therapeutic radiology 
simulation (77280, 77290).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve selenium sulfide. 
 
You asked the Plan to pre-approve the medication. You say that you say the requested drug is medically 
necessary. 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 selenium sulfide.  
 
Benefits for the medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a denosumab injection provided on 
September 19, 2023. 
 
You asked the Plan to waive the coinsurance for a denosumab injection. You say that you do not agree with the 
cost sharing. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for in-network Medicare Part B chemotherapy drugs, associated administration services and all 
other Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for a denosumab injection. This item/service falls within the in-network Medicare Part B chemotherapy drugs, associated administration services and all other Medicare Part B 
drugs benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
The total you owe is $287.92 because the Plan is only holding you responsible for this amount which is less 
than the 20% coinsurance. Therefore, we decided that the Plan does not have to waive the coinsurance for a 
denosumab injection provided on September 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that this procedure would benefit the 
enrollee. The Plan denied your request. The Plan says medical studies have not shown this service is proven 
helpful for the enrollee's back pain. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without 
facet joint disease or stenosis. The cause of pain is also not clear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory assist device (E0470) and heated humidifier 
(E0562), provided on June 29, 2023. 
 You asked the Plan to pay for the respiratory assist device and heated humidifier . You say that the item was 
medically necessary. The Plan denied your request. The Plan says there is no recent evidence of adherence to 
use of the PAP device. 
 
The Plan must follow Medicare rules. Medicare rules say that for PAP devices with initial dates of service on 
or after November 1, 2008, documentation of clinical benefit is 
demonstrated by: 
1. In-person clinical re-evaluation by the treating practitioner with documentation that symptoms of obstructive 
sleep apnea are improved; and, 
2. Objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the respiratory assist device  and heated humidifier  have not been met. Therefore, we decided that 
the Plan does not have to pay for the respiratory assist device (E0470) and heated humidifier (E0562), provided 
on June 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6740 x2). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says the enrollee's benefit for the requested item or service has been exhausted with the 
Plan's approval for 3 retainer crowns.  

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the enrollee's benefit for the requested item or service was exhausted with the Plan's approval of 3 
retainer crowns. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6740 x2).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 additional skilled nursing visits and 6 additional 
physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 5 additional skilled nursing visits and 6 additional PT visits. You say that 
this is for a discharge visit. You also say that a total of 8 visits were done but only 7 were approved. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 5 additional skilled nursing visits and 6 
additional PT visits. Our reviewer says that the requested additional skilled nursing and PT services are not 
medically reasonable and necessary. Our physician reviewer found the provided documentation does not show 
that the enrollee has skilled nursing needs. The enrollee does not have documented skilled therapy needs. The 
enrollee is functioning at a level commiserate with a lower level of care. Therefore, the reviewer found that the 
requested additional skilled nursing and PT services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 5 additional skilled nursing visits and 6 additional PT visits. have not been met. 
Therefore, we decided that the Plan does not have to pre-approve 5 additional skilled nursing visits and 6 
additional physical therapy (PT) visits.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have pay for SNF services provided from March 15, 2023, through April 8, 
2023.  
 
You asked the Plan pay for SNF services. You say that the SNF admission was medically necessary. The Plan 
denied your request. The Plan says SNF services provided from March 15, 2023, through April 8, 2023, were 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from December 5, 
2022, through March 14, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have pay for SNF services provided from March 15, 2023, through April 8, 2023.
Appeal type: Home Health
Decision: Unfavorable


We decided that the Plan does not have to pay for the home health services for date of service May 19, 2022, to June 2, 2022.

You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied. 

The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of care date for home health services. NOAs which are received more than 30 days from the timely filing date result in no payment being made for the episode of care. 

In this case, the start of care date is April 19, 2022. The NOA was not received by the Plan until November 30, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services for date of service May 19, 2022, to June 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ondansetron. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee reports nausea associated with 
meals/snacks. 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 ondansetron.