Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient psychotherapy services (90832) provided on 
October 26, 2022. 
 
You asked the Plan to pay for outpatient psychotherapy services. You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of outpatient psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for outpatient psychotherapy 
services (90832) provided on October 26, 2022.
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 the services will help the enrollee to regain their 
strength and independence to return home. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for admission to 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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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: 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 it is medically necessary. The Plan denied your 
request. The Plan says you 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 the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for surgery for vertebral fractures medical problems are stable. There are no complex 
nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that the enrollee 
needs transportation for a medical appointment. The Plan denied your request. The Plan says the enrollee's 
benefit only allows 48 one-way trips with each one-way trip not exceeding 50 miles of driving distance. 
 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 routine transportation when the driving distance for a one-way trip is within 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, the provider is 
located 60.6 miles away from the enrollee's residence. The Plan only covers distances up to 50 miles. 
Therefore, we decided that the Plan does not have to pre-approve additional mileage for routine transportation 
(A0170).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter implantation of wireless pulmonary artery 
pressure sensor (CardioMEMS) (33289, C2624). 
 
You asked the Plan to pre-approve CardioMEMS. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no indication of clinical trial. 
 
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 CardioMEMS. Our reviewer says that 
there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of CardioMEMS in patient management. Our physician reviewer found at this time, the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical 
management.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter implantation of wireless pulmonary artery pressure sensor (CardioMEMS) 
(33289, C2624).
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 you would like reconsideration because the services 
are medically necessary. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and your needs can be met at an alternate 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 you do not need physician supervision 3 times a week or intensive therapy 3 
hours a day and 5 days per week with a multidisciplinary approach in an IRF. While you may benefit from 
physical and occupational therapy your needs can be provided in an alternate setting such as skilled nursing 
facility. 
 
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 the paramedic intercept services.  
 
You asked the Plan to pay for the paramedic intercept services. You say that the services were not requested by 
you but were requested by 911. The Plan denied your request. The Plan says this item is not a covered benefit. 
 The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says facet joint injections 
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 facet joint injections. Our reviewer says 
that facet joint injections are medically necessary. Our physician reviewer found the enrollee had a previous 
lumbar radiofrequency ablation at the same level in November of 2022, and there is no documentation of why 
the enrollee is not a candidate for radiofrequency ablation. Therefore, the enrollee does not meet the LCD 
criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the primary care provider office visit 
provided on February 03, 2023. 
 
You asked the Plan to waive the copayment for the primary care provider office visit. You say that this was 
part of your annual physical exam and should have no copayment. 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 $10 
copayment for primary care provider/practitioner services. 
 
You have been asked to pay a $10 copayment for the primary care provider office visit. This item/service falls 
within the primary care provider/practitioner services 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 records show the Plan has reprocessed the claim to apply the 
proper $10 primary care office visit copayment. Therefore, we decided that the Plan does not have to waive the 
copayment for the primary care provider office visit provided on February 03, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
you would like this request to be reconsidered. The Plan denied your request. The Plan says there is not a 
medical need to control these power options through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has left hemiplegia, and does 
not have significant right sided weakness. Our reviewer also found that the enrollee has adequate strength to 
manage standard power drive controls. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulmonary diagnostic testing and therapies provided on 
November 09, 2022. 
 
You asked the Plan to pay for pulmonary diagnostic testing and therapies. You say that the services should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for pulmonary diagnostic 
testing and therapies provided on November 09, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-complete series of radiographic images (D0210) 
provided on February 17, 2023. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
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 service provided was exhausted on date of service June 8, 2022.  
  
 
Specifically, the Plans contract states that a full mouth x-ray is covered once every 24 months. You previously 
received this service on June 8, 2022, less than 24 months prior, which was paid for by the Plan. Therefore, you 
have exhausted the allowable benefit for this service. Therefore, we decided that the Plan does not have to pay 
for the intraoral-complete series of radiographic images (D0210) provided on February 17, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a computed tomography (CT) of the face received on January 13, 2023. 
 
You asked the Plan to pay for the CT scan. You say that the services were medically necessary for left sided 
face pain that lasted for months. The Plan denied your request. The Plan says that the records do not show that 
a CT scan was needed.  
 
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 pay for the CT scan. Our reviewer says that the CT 
scan was medically necessary. Our physician reviewer found the records from November 2022 document an 
incomplete response to Flonase and persistent right sided facial pain extending to the brain. Plain x-ray on 
August 20, 2022 were negative. It was reasonable to order a CT scan of the sinuses. The CT scan was 
reasonable after appropriate conservative management and persistence of symptoms. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CT scan have been met. Therefore, we decided that the Plan has to pay for a 
computed tomography (CT) of the face received on January 13, 2023.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for resin-based composite - four or more surfaces, 
posterior (D2394) provided on January 4, 2022, to July 1, 2022. 
 
You asked the Plan to pay more for the resin-based composite - four or more surfaces, posterior. You say that 
are requesting reconsideration of the claim for dental services. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. The Evidence of Coverage clearly states that the dental allowance is based 
on the amount the enrollee actually paid for the dental services, not the billed amount. 
 
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 for the services up-front and we will reimburse you 
50% of the amount you paid, up to a maximum yearly reimbursement of $1,000 every year for non-Medicare 
covered preventive dental services and non-Medicare covered comprehensive dental services combined. You 
are responsible for any amount above the dental coverage limit. 
 
You have been asked to pay a 50% coinsurance for the resin-based composite - four or more surfaces, 
posterior. This service falls within the Additional dental services allowance 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 pay more for resin-based composite - four or more surfaces, posterior (D2394) provided on 
January 4, 2022, to July 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on December 
20, 2022. 
 
You asked the Plan to pay for the Cxbladder detect test. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder detect test have not been met. Therefore, we decided 
that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on December 20, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a fluid swing and stance phase control (L5828), fluid stance 
extension (L5848), microprocessor control feature (L5856), and stance flexion feature (L5845). 
 
You asked the Plan to pre-approve a fluid swing and stance phase control, fluid stance extension, 
microprocessor control feature, and stance flexion feature. The Plan denied your request. The Plan says that 
this request for K3 microprocessor knee does not meet Medicare criteria as reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a fluid, pneumatic, or electronic/microprocessor knee 
is covered for beneficiaries whose functional level is 3 or above. 
 
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 fluid swing and stance phase control, 
fluid stance extension, microprocessor control feature, and stance flexion feature. Our reviewer says that the 
criteria for coverage are met. Our physician reviewer found the medical record more than meets the standard 
for documenting the enrollee's K3-status, and then goes above and beyond by describing the microprocessor 
knees particular utility for the enrollee. The Plan meanwhile appears to not dispute the enrollee's K3 status, in 
that they have approved L5987. Our reviewer found that a purely mechanical knee would be sub-standard care 
for an enrollee like this for numerous reasons that are beyond the scope of this review, but in any event, it is not 
up to the Plan to second guess the treatment decisions of the local physician and Certified Prosthetist/Orthotist 
(CPO), who met their documentary burden up front simply by proving the enrollee's K3-level. Our physician 
reviewer found that the microprocessor knee (L5828, L5845, L5848, L5856) is hereby approved. 
 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 fluid swing and stance phase control, fluid stance extension, microprocessor 
control feature, and stance flexion feature have been met. Therefore, we decided that the Plan has to pre-
approve a fluid swing and stance phase control (L5828), fluid stance extension (L5848), microprocessor 
control feature (L5856), and stance flexion feature (L5845).  
 
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.