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

 
We decided that the Plan does not have to pre-approve an MRI or a PET scan. 
 
You asked the Plan to pre-approve an MRI or PET scan. You say that an MRI or PET scan are medically 
necessary due to a fall. The Plan denied your request. The Plan says an MRI or PET scan are not medically 
necessary. The member has been referred to occupational and physical therapy for treatment of wrist and hip 
pain. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary. Medicare rules say that 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 MRI or PET scan. Our reviewer says 
that the requested MRI or PET scan is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you had a slip and fall injury of right hip and left wrist on January 15, 2023.  
X-rays have been negative. You have been seen by an occupational therapist but you request an MRI and PET 
scan. Evaluation by your PCP indicates MRI and PET not indicated. You have no fractures and you are 
currently receiving occupational therapy. No medical necessity for your request of an MRI or a PET is 
documented by any clinician or occupational therapy personnel. 
 
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 MRI or PET scan have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an MRI or PET scan.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography angiography (CTA) of the chest. 
 
You asked the Plan to pre-approve the CTA of the chest. You say that the services are medically necessary. 
The Plan denied your request. The Plan says that the services are 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 the CTA of the chest. Our reviewer 
says that the CTA is medically necessary. Our physician reviewer found the critical information about the 
anatomy of the Left atrial appendage is essential for a successful watchman device in the above individual. The 
CTA needs to be done until the needed information is captured. 
 
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 CTA of the chest have been met. Therefore, we decided that the Plan has to 
pre-approve a computed tomography angiography (CTA) of the chest.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Farxiga tablets 10mg. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. The Plan denied 
your request. The Plan says there are no Part D benefits with this 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 Farxiga tablets 10mg.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliances (E0656, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that the 
Flexitouch compressor is the only compressor that can provide the therapy that the enrollee needs. The Plan 
denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema 
pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliances (E0656, E0667).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutments (D6057 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 enrollees benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows the enrollees benefit for the requested item or service was exhausted on date of service April 10, 2023. 
Therefore, we decided that the Plan does not have to pre-approve custom fabricated abutments (D6057 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildups (D2950 x3). 
 
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 your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 26, 2023. Therefore, 
we decided that the Plan does not have to pre-approve core buildups (D2950 x3).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service November 
22, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service November 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has complex medical and 
respiratory needs that can be met at LTACH level of care. The Plan denied your request. The Plan says an 
LTACH admission is not medically necessary.  
 
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 that the enrollee is receiving the care they need in the current acute setting. There are 
no clear added treatments that would be provided by the LTACH. 
 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 LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that without continued PT services, the 
enrollee's quality of life, independence, and safety are at risk of decline. The Plan denied your request.  The Plan says the enrollee is getting PT for their mobility and their function has improved. The Plan also says 
that the enrollee has reached reasonable goals for daily task, and more skilled treatment is not needed at this 
time. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. Our reviewer also found that the additional therapy services are not an appropriate duration and 
frequency for treatment of the enrollee's medical condition and therefore are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 30 additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve the additional trips. You say that you are blind and need the transportation 
as you can't drive. You also say that you have dialysis two times a week. The Plan denied your request. The 
Plan says your benefit only allows 24 trips for this service and you have exceeded your benefit limit. 
 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 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to approve an 
additional 30 routine transportation trips. 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 30 additional routine transportation trips (A0120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Levonorgestrel-releasing intrauterine contraceptive system 
(IUD, mirena, 52 mg. 
 
You asked the Plan to pay for the services. You say that the doctor's office did not know which code to use. 
The Plan denied your request. The Plan says contraception is not covered. 
 
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing 
conception (contraception) are not considered medically reasonable and necessary.  
 
Records show that the requested service is primarily for the purpose of contraception. The documentation does 
not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for coverage of this item/service have not been met. Therefore, we decided that the Plan does not have to pay for 
Levonorgestrel-releasing intrauterine contraceptive system (IUD, mirena, 52 mg.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that your previous dentures broke, and you 
need a replacement. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 20, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a lower partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve care from an out-of-network (OON) tertiary care 
provider at the in-network benefit level.  
 
You asked the Plan to pre-approve care from an OON tertiary care provider at the in-network benefit level. 
You say that your primary care provider and your orthopedic specialist referred you to the requested OON 
provider. You say that both doctors said that the only possible solution for your continuous pain was to get care 
from the tertiary level of care provider. You say that the requested OON provider is best suited to treat your 
condition and no other institution could do so effectively.  The Plan denied your request. The Plan says the 
records provided do not support the need for OON care. The Plan says that there are in-plan providers available 
who can treat your condition.  
 
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 care from an OON tertiary care 
provider at the in-network benefit level. Our reviewer says that the criteria for coverage of OON care have not 
been met.  Our physician reviewer found the record does not document the presence of unique characteristics 
of your condition that would necessitate tertiary level care. The Plan's denial is medically justified on the basis 
that it is offering adequate care to meet your medical needs to network non-tertiary level of care providers.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of care from an OON tertiary care provider at the in-network benefit level have not 
been met. Therefore, we decided that the Plan does not have to pre-approve care from an out-of-network 
(OON) tertiary care provider at the in-network benefit level.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 30, 2023, billed with 
procedure codes 96365-59, 96366-59, and 96521. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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, the CPT Code Manual definition of codes 96365-59, 96366-59, and 96521 is Intravenous infusion, 
for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1-hour, Intravenous infusion, 
for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in 
addition to code for primary procedure), and refilling and maintenance of portable pump. 
 We asked our coder 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 the practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that codes 96365 and 96366 are not 
supported as there is a more appropriate code that should be reported for documented services provided. The 
medical record includes a physician order for code 96521, however the procedure cannot be verified as 
performed, as it was not documented in medical record. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on March 30, 2023, billed with procedure codes 
96365-59, 96366-59, and 96521.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
dermatologist.  
 
You asked the Plan to pre-approve a continuation of care with an OON dermatologist. . You say that the 
enrollee is well-established and feels comfortable with the OON provider as her dermatologist.  The Plan 
denied your request. The Plan says there are participating dermatology providers in-network who can treat the 
enrollee's medical conditions.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees 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 a continuation of care with an OON 
dermatologist. Our reviewer says that the criteria for coverage have not been met.  Our physician reviewer 
found the enrollee has Rosacea, which is a common skin disease. There is nothing unique about the enrollee's 
condition that would make it medically necessary for her to continue care with the OON provider. The Plan has 
shown that they have in-network providers who meet the current medical Standards of Care required for 
treatment of the enrollee's condition. The enrollee's medical management and follow-up care can be safely 
transitioned to an in-network specialist at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a continuation of care with an OON dermatologist.  have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuation of care with an out-of-network 
(OON) dermatologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5211). 
 
You asked the Plan to pre-approve the dental services. You say that this is necessary. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 1, 2023. Therefore, 
we decided that the Plan does not have to pre-approve an upper partial denture (D5211).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a kidney transplant. 
 
You asked the Plan to pre-approve a kidney transplant. You say that the Plan is 'playing with your life' and this 
transplant should be approved. The Plan denied your request. The Plan says that your medical records do not 
show that you are actively involved in a weight loss program. You have not started a walking program as 
directed by your doctor and your lab testing does not show that you are abstaining from tobacco or other 
substances. You are still using marijuana and you have not submitted the results of a pulmonary function test. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 kidney transplant. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, the record indicates that you have end stage renal disease and are on dialysis.  You 
have been appropriately evaluated at the transplant center, which is both a United Network for Organ Sharing 
(UNOS) and Centers for Medicare and Medicaid Services (CMS)-approved kidney transplant program and 
have been deemed an appropriate candidate by the patient selection committee for renal transplantation. The 
record provided is sufficient to establish the medical necessity and reasonableness, as defined by Medicare 
rules,  of the requested service. 
 
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 kidney transplant have been met. Therefore, we decided that the Plan has to 
pre-approve a kidney transplant.  
 
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.