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

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the abdomen. 
 
You asked the Plan to pre-approve the MRI of the abdomen. You say that the services are medically necessary. 
The Plan denied your request. The Plan says there are no notes showing why the service is needed.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI of the abdomen. Our reviewer 
says that the MRI is not medically necessary. Our physician reviewer found the MRI of the abdomen is being 
requested to look for possible insulinoma. However, based on the provided history, the high C-peptide score 
was not surprising or clinically relevant. The glipizide use could have raised this level, the enrollee could have 
been non-fasting during the test, and a normal or high level is common with type 2 diabetes, which they have. 
There were no other indications for advanced imaging, such as an abnormal examination finding or other red 
flags. Therefore, without sufficient support made for MRI abdomen, it will be considered not medically 
necessary 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 the MRI of the abdomen have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a magnetic resonance imaging (MRI) of the abdomen.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept (A0432) provided on January 6, 2023. 
 
 
 You asked the Plan to pay for the paramedic intercept. You say that you do not agree with the claim denial and 
provider bill you received from the volunteer emergency ambulance service. You also say that you are only 
going to pay for the other ambulance for the services that were rendered. The Plan denied your request. The 
Plan says paramedic intercept services are not covered in non-rural locations. 
 
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 paramedic 
intercept (A0432) provided on January 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home ventilator (E0466) provided on January 18, 2023. 
 
You asked the Plan to pay for the home ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the home ventilator. Our reviewer says that 
the enrollee does not need this item. Our physician reviewer found the provided records document that the 
home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with 
auto-EPAP (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. The records in 
this case do not provide adequate detailed information to meet Medicare criteria for coverage of a ventilator as 
opposed to a BiPAP device with AVAPS and a back-up rate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pay for the home ventilator (E0466) provided on January 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the device is medically necessary. The Plan 
denied your request. The Plan says the provider has prescribed a ventilator to help the enrollee breathe at 
various times of the day (night and day) because of lung disease. Medicare does not cover ventilators used in 
this way. Medicare will cover a device called respiratory assist device that has advanced features, and the plan 
will cover this when medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD, congestive 
heart failure, atrial fibrillation, and coronary artery disease. The enrollee was admitted March 4, 2023, with 
acute exacerbation of COPD and heart failure. Arterial blood gas was consistent with acute on chronic 
hypercarbic respiratory failure. Pulmonary function tests confirm severe obstructive lung disease. There is no 
ABG done while stable to document chronic CO2 retention. If that is present, the enrollee may benefit from 
BiPAP with AVAPS during sleep as an outpatient. Medicare does not cover a home ventilator when used at 
settings that can be provided with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service March 8, 
2022, to April 6, 2022. You asked the Plan to pay for the billed services. You say that an NOA was submitted. 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 March 8, 2022. The NOA was not received by the Plan until July 27, 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 care billed for dates of 
service March 8, 2022, to April 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from December 18, 2022, 
to December 20, 2022. 
 
You asked the Plan to pay for the medication. You say that you were hospitalized and did not take any 
medication that was not directed by a physician. 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 pay for self-administered drugs provided 
from December 18, 2022, to December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custom fabricated abutment (D6057) and abutment supported 
crown (D6058) provided on February 8, 2023. 
 
You asked the Plan to pay for implants and associated services. You say that this should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for custom 
fabricated abutment (D6057) and abutment supported crown (D6058) provided on February 8, 2023.
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 without intensive therapies the enrollee will remain 
at a significantly high risk for further pressure ulcers, skin breakdown, further functional decline, decreased 
mobility, and death. The Plan denied your request. The Plan says a SNF admission is not medically necessary, 
and the enrollee's needs can be safely received in a different setting.  
 
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 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panoramic radiographic image for the upper and lower 
jaw (D0330). 
 
You asked the Plan to pre-approve this dental service. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested 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 service was exhausted on date of service January 26 2022.  
  
 
Specifically, the Plans contract states that a panoramic radiographic image is covered once every 36 months. 
You previously received this service on January 26, 2022, less than 36 months prior, which was paid for by the 
Plan. Therefore, you have exhausted the allowable benefit for the requested service at this time. Therefore, we 
decided that the Plan does not have to pre-approve a panoramic radiographic image for the upper and lower jaw 
(D0330).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from January 1, 2022, to January 21, 
2022. 
 You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says the enrollee no longer had 
skilled nursing facility 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 pay for 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 the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did 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 pay for SNF care provided from January 1, 2022, to January 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you have a lot of back, hip pain and 
history of falls.  The Plan denied your request. The Plan says you are functional with in-home and short 
distance gait with use of your cane, which was demonstrated during your assessment.  
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer says that this item is not medically necessary. Our physician reviewer found you are independent with mobility with 
the assistance of a cane in your home and a walker in the community. You can independently perform your 
daily activities. You do not require a power mobility device for mobility and performing daily activities in the 
home and have availability of transportation for community access. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the home infusion therapy services 
provided from May 19, 2021, to October 12, 2022. 
 
You asked the Plan to waive the copayments for the home infusion therapy services. You say that you were 
billed for 34 months of service all at once. 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 2021 contract with the Plan clearly says that you must pay a 
$15 copayment for each home infusion therapy service. Your 2022 contract with the Plan also clearly says that you must pay a $15 copayment for each home infusion therapy service. 
 
You have been asked to pay a $15 copayment for each home infusion therapy services. This item/service falls 
within the home infusion therapy service 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 copayments 
for the home infusion therapy services provided from May 19, 2021, to October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the viable disc nucleus pulposus (NP) tissue allograft 
(0627T). 
 
You asked the Plan to pre-approve the Via Disc NP. You say that this service is medically necessary. The 
Plan denied your request. The Plan says this is an experimental procedure. 
 
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 the Via Disc NP. Our reviewer says 
that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is an experimental procedure. 
 
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 Via Disc NP have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the viable disc nucleus pulposus (NP) tissue allograft (0627T).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
September 24, 2022, to September 27, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
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 $335 per 
day for days 1-6. for inpatient hospital care.  
 
You have been asked to pay $335 per day for days 1-6. for inpatient hospital care. The total amount you are 
being asked to pay is $1,005 ($335 x 3 days = $1,005). This item/service falls within the inpatient hospital care 
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 inpatient hospital care provided 
on September 24, 2022, to September 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair, group 2 standard, single power 
option (K0836) and accessories (K0108, E2603, E2361, E2311, E1028, E1012, E1002, E0955). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested wheelchair 
and accessories are medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for approval of the requested wheelchair and accessories. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 The file does not show that the enrollee has a mobility deficit that impairs her participation in MRADLs. The 
records do not show information included on the seating and mobility examination and that the enrollee is 
unable to complete self-care tasks in the home with the 4 wheeled walker, cane, or manual wheelchair. This 
means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair, group 2 standard, single power option (K0836) and accessories 
(K0108, E2603, E2361, E2311, E1028, E1012, E1002, E0955).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have  to waive the coinsurance for dental x-rays provided on February 10, 
2023. 
 
You asked the Plan  to waive the coinsurance for dental x-rays. You say that this should be covered. 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 50% 
coinsurance for Dental.  
 
You have been asked to pay 50% coinsurance for dental x-rays. This item/service falls within the Dental 
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 coinsurance for dental x-rays provided on 
February 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the enrollee does not need this item. Our physician reviewer found there are no pulmonary function tests to confirm airways obstruction and assess severity or a diagnosis of thoracic restrictive disease or neuromuscular 
disease.  There is no arterial blood gas (ABG) done while stable to document chronic carbon dioxide (CO2) 
retention.  If that is present, the patient may benefit from BiPAP with AVAPS during sleep.  Medicare does not 
cover a home ventilator when used at settings that can be provided with BiPAP.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).