Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injection. 
 
You asked the Plan to pre-approve repeat epidural steroid injection. You say that the enrollee will not regain 
normal function if she does not get this done. The Plan denied your request. The Plan says the records do not 
show a repeat injection is appropriate when the enrollee hasn't shown at least a 50% improvement in pain 
and/or function for at least three months. 
 
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 repeat epidural steroid injection. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the LCD criteria 
requires 50% pain relief for 3 months. This was not achieved and therefore, the request is deemed as not 
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 repeat epidural steroid injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve repeat epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that the enrollee suffers from severe 
chronic respiratory failure secondary to COPD, and alternate treatments such as bi-level and CPAP have 
proven to insufficient in providing the necessary targeted modalities, variable pressures, alarms, and battery 
backup. The Plan denied your request. The Plan says a home ventilator is not medically necessary for this 
patient because their needs can be met with an alternative device such as a BiPAP device with average volume-
assured pressure support (AVAPS).  
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that there is a 
history of asthma, but the enrollee has never smoked. However, there are no pulmonary function tests to 
confirm airways obstruction or assess severity. Also, there is no diagnosis of thoracic restrictive disease or 
neuromuscular disease. The enrollee may benefit from a BiPAP with volume assurance during sleep as an 
outpatient if compliance can be achieved. The records do not show that this has been tried, and therefore a 
home ventilator 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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you are not able to take care of yourself due to 
having a stroke. You say that you do not have anyone to assist you if you fall. The Plan denied your request. 
The Plan says a SNF admission is not medically necessary.  
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that 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. You do not require 
daily skilled nursing 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 3 reader (A9278).  
You asked the Plan to pre-approve a FreeStyle Libre 3 reader. You say that the patient has a history of 
hyperglycemia. The Plan denied your request. The Plan says the use of this drug is not reasonable and 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a FreeStyle Libre 3 reader have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a FreeStyle Libre 3 reader (A9278).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure. 
 
You asked the Plan to pre-approve the Minuteman procedure. You say that you need the operation due to 
having tried other options prior to surgery. You say that you have had many failures with other treatments, and 
this is the last options to help you with relief of symptoms. The Plan denied your request. The Plan says a 
posterior lumbar arthrodesis procedure is considered experimental and investigational.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a posterior lumbar arthrodesis 
procedure. Our reviewer says that the Minuteman procedure is considered experimental and investigational. 
Our physician reviewer found that there is a lack of large-volume, long-term peer-reviewed outcome studies to 
support the use of this device for your medical condition. Additionally, there are multiple alternate pain 
generators plausibly significantly contributing to the clinical condition that have not been fully documented as 
having been excluded or ruled out. Furthermore, no compelling rationale is presented, or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
Minuteman procedure at L4-5 is not medically reasonable or necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Minuteman procedure.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on July 
16, 2023. 
 
You asked the Plan to pay for the ED services. You say that you are requesting the claim be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says Medicare payment cannot be made to 
this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
 
  We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on July 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-ambulance non-emergency medical transportation 
(NEMT).  
You asked the Plan to pre-approve the NMET. You say that the request came from the physician who referred 
you to a specialist as they are unable to help her. You also say that you are unable to drive and she does require 
assistance getting in and out of vehicles, that you will be providing as you will be present. The Plan denied 
your request. The Plan says your provider did not submit any clinical information to establish medical necessity 
for the requested service. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 the non-ambulance non- emergency 
transportation have been met. There were no medical records provided. Without this necessary information, we 
are unable to determine whether the criteria for coverage have been met. The Plan has shown that they made 
reasonable attempts to obtain this necessary information. Therefore, we decided that the Plan does not have to 
pre-approve non-ambulance non-emergency medical transportation (NEMT).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
January 29, 2023. 
 
You asked the Plan to pay for the ED services. You say that you are requesting the claim be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says Medicare payment cannot be made to 
this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on January 29, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
26, 2023. 
 
You asked the Plan to pay for procedure code 70450. You say that you are requesting the claim be reviewed 
and reprocessed for payment. The Plan denied your request. The Plan says payment for code 70450 is bundled 
into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service September 26, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gastroenterology care with an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve gastroenterology care. You say that the Plan does not have an in-network 
provider that specializes in high-risk polyp removal, and this is the only provider who can accommodate your 
medical needs safely. The Plan denied your request. The Plan says this provider is out-of-network with the Plan 
and you can be treated within the Plan network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 gastroenterology care. Our reviewer 
says that you do not meet criteria for care with an out-of-network provider. Our physician reviewer found the 
Plan is offering adequate to meet your needs through referral to an in-network provider. The documentation 
does not support that there is anything unique about your condition that would make it medically necessary for 
you to see the requested out-of-network provider. The Plan has shown that they have in-network providers who 
meet the standards of care required for treatment of your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of gastroenterology care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve gastroenterology care with an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation-diagnostic service provided by a dentist or 
physician other than requesting dentist or physician (D9310) on September 29, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not covered under the 
supplemental dental policy.  
 
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 service provided is not among 
those covered under this benefit.  
  
 
Therefore, we decided that the Plan does not have to pay for the consultation-diagnostic service provided by a 
dentist or physician other than requesting dentist or physician (D9310) on September 29, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF admission and services.  
 You asked the Plan to pre-approve SNF care. You say that the enrollee would benefit from a short-term SNF 
admission before being discharged home. The Plan denied your request. The Plan says the enrollee has no daily 
skilled nurse or therapist needs. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not meet the severity of illness or the intensity of service criteria for 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx- SCC gene expression test (0315U). 
 
You asked the Plan to pay for DecisionDx- SCC gene expression test. You say that the service was medically 
necessary. The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that Molecular Diagnostic Services Program 
(MolDX) will review all new test/assay clinical information to determine if a test meets Medicares 
reasonable and necessary requirement. Labs must submit a comprehensive dossier on each new test/assay prior 
to claim submission. MolDX will only cover and reimburse tests that demonstrate analytical and clinical 
validity, and clinical utility at a level that meets the Medicare reasonable and necessary requirement.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of DecisionDx- SCC gene expression test have not been met. Therefore, we decided that the Plan 
does not have to pay for DecisionDx- SCC gene expression test (0315U).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an injection provided on November 9, 2022. 
 
You asked the Plan to pay for an injection. You say that this was medically necessary. The Plan denied your 
request. The Plan says that a freestanding ER is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that there is no evidence this is a freestanding ER or that the provider is 
not enrolled in Medicare. Therefore, we decided that the Plan has to pay for an injection provided on 
November 9, 2022.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that this is medically necessary. The Plan denied 
your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found there was no indication in the records that 
the enrollee met diagnostic criteria for either let alone both AD and FTD. 
 
   
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy and 
esophagogastroduodenoscopy provided on June 12, 2023. 
 
You asked the Plan to waive the copayment for a colonoscopy and esophagogastroduodenoscopy. You say that 
the cost share is wrong. 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 a $325 
copayment for outpatient surgery.  
 
You have been asked to pay a $325 copayment for a colonoscopy and esophagogastroduodenoscopy. This 
item/service falls within the outpatient surgery 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. Therefore, we decided that the Plan does not have to waive the 
copayment for a colonoscopy and esophagogastroduodenoscopy provided on June 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthoses billed for date of service May 16, 2023. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
 The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. Based on this information, we decided that the Medicare rules 
for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the orthoses 
billed for date of service May 16, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services without transport on October 11, 2023. 
 
You asked the Plan to pay for ambulance services without transport. You say that you were told that your vital 
signs were normal and you did not need to go to the emergency room. The Plan denied your request. The Plan 
says ambulance services without transport are never covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 11, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services without transport on October 
11, 2023.