Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the 
enrollee on April 4, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. 
The Plan denied your request. The Plan says the services are not supported by the records. 
 
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 orthosis. Our reviewer says that the 
enrollee does not meet criteria for the orthosis ordered. Our physician reviewer found the enrollee's chief 
complaint was right anterior shoulder pain. The documentation in the case file does not support that the 
requested shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case. A 
physical examination of the shoulder would reasonably be required to adequately assess whether the 
shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the 
orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient 
documentation of a credible physical examination of the shoulder. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on April 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lower limb prosthesis provided on March 10, 2020. 
 
You asked the Plan to pay for the lower limb prosthesis. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization.  
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
lower limb prosthesis. We found no exception that would require the Plan to pay for these items. Therefore, we 
decided that the Plan does not have to pay for a lower limb prosthesis provided on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) on February 
4, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you were told you would 
not be responsible for this copayment. The Plan denied your request. The Plan says the correct copayment was 
applied. 
 
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 $45 
copayment for services furnished by a specialty physician in an outpatient clinic.  
 
You have been asked to pay a $45 copayment for a specialist office visit. A specialist office visit falls within 
the "Outpatient hospital 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. Therefore, we decided that the Plan does not have to waive the copayment for a 
specialist office visit (99213) on February 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 12, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician's services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vitamin D and hemoglobin testing provided on January 
23, 2020. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the services are 
not a covered benefit for the diagnosis listed. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal was provided for screening purposes. There are insufficient records to show the 
results of the testing will be used for a specific treatment strategy. Medicare does not cover this testing for 
screening purposes. Therefore, we decided that the Plan does not have to pay for the Vitamin D and 
hemoglobin testing provided on January 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a user-adjustable heel height feature (L5990) for a 
prosthesis. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a a user-adjustable heel height feature (L5990) 
will be denied as not reasonable and necessary. 
 
All but one of the requested codes have been approved. The remaining denied code - L5990 - is statutorily not 
covered. Based on this information, we decided that Medicare rules for coverage of the services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a user-adjustable heel height feature 
(L5990) for a prosthesis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services rendered on September 19, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 99291 and 99292 are not supported. 
 
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 code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. The definition of code 99292 is critical care, 
evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List 
separately in addition to code for primary service). 
 
We find that CPT codes 99291 and 99292 are not supported in the medical record. Specifically, the submitted 
critical care note indicates multiple conflicting dates, including September 20, 2019 and the result date is 
September 19, 2019. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services 
rendered on September 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for a CPAP device out-of-network. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are in-network providers available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral for a CPAP device out-of-network.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fully-reclining wheelchair (E1060) purchased  on February 
28, 2020. 
 
You asked the Plan to pay for the fully reclining wheelchair. You say that the plan denied that this is not 
covered by Medicare, however, Medicare Part B does cover wheelchairs as durable medical equipment. You 
have provided the doctor's prescription and copy of the wheelchair invoice. The Plan denied your request. The 
Plan says the plan cannot pay a provider who is not eligible to participate in Medicare. If you go to a provider 
who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you 
receive. 
 
The Plan must follow Medicare rules. The rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider and supplier enroll in the Medicare program. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the non-Medicare 
participating provider. Therefore, we decided that the Plan does not have to pay for a fully-reclining wheelchair 
(E1060) purchased  on February 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that  a power seat elevation feature is non-covered 
because it is e not primarily medical in nature. 
 
We looked at the file and Medicare rules. The requested item is non-covered. Based on this information, we 
decided that Medicare rules for coverage of a power seat elevation system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal decompression and possible fusion of L4 to L5. 
 
You asked the Plan to pre-approve spinal surgery. You say that you do not feel that therapy will help until after 
surgery, and you are in excruciating pain. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because this surgery 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 spinal surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation of a recent trial and failure of adequate physical therapy. More 
conservative measures are needed for lower back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal decompression and possible fusion of L4 to L5.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom-fabricated abutment and implant-supported 
crown for the enrollee. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee will soon experience bone loss 
without this. The Plan denied your request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
custom-fabricated abutment and implant-supported crown for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation with an oral surgeon for an extraction. 
 
You asked the Plan to pre-approve the consultation. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not to be provided by an oral surgeon. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers dental 
services when provided by a participating general dentist.  
 
These services are not to be provided by a general dentist. An oral surgeon is not a covered provider type. 
Based on this information, we decided that the Plan's rules for coverage of the consultation have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a consultation with an oral surgeon for an 
extraction.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildups for teeth #s 8 and 9 coded as D2950. 
 
You asked the Plan to pre-approve the core buildups. You say that the buildup is necessary as well as the crown 
in order to ensure crown retention. The Plan denied your request. The Plan says although this service may be 
necessary, it is not among those covered by the Plan. 
 
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 pre-approve core 
buildups for teeth #s 8 and 9 coded as D2950.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve full time sitter services or a walk-in bathtub. 
 
You asked the Plan to pre-approve full time sitter services or a walk-in bathtub. You say that you like the sitter 
service and you are not ready to be alone yet. You say you need a walk-in bathtub because you call 911 to get 
you out every time you take a bath. The Plan denied your request. The Plan says custodial services and walk-in 
tubs are not covered by the Plan or Medicare. 
 
The Plan must follow Medicare rules. The rules say that custodial care is not covered. 
 
We looked at the file and Medicare rules. The service you are requesting is custodial care and custodial care is 
not a covered benefit. A walk-in bathtub is not considered to be durable medical equipment per Medicare 
Guidelines. Also, Medicare does not cover home modifications. Based on this information, we decided that 
Medicare rules for coverage of full time sitter services or a walk-in bathtub have not been met. Therefore, we 
decided that the Plan does not have to pre-approve full time sitter services or a walk-in bathtub.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve CT scan of the chest for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the new 2mm nodule does not require a repeat CT sooner than one year. 
 
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 scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee is high risk 
due to smoking history. While there are multiple stable nodules there is a new 2 mm nodule since both 7/17/19 
and 1/21/20 in a high risk patient. As such the accepted guidelines allow for closer surveillance than 1 year for 
new nodules in high risk patients. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
CT scan of the chest for the enrollee.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back and 
knee pain with spasticity in the lower limb. She has had two diagnostic genicular nerve blocks that provided 
significant, but short-lived, relief. Genicular RFA for spasticity is considered experimental/investigational in 
nature and is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular radiofrequency ablation (RFA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a refraction procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that these services were previously covered in 2019. 
The Plan denied your request. The Plan says this is not a covered service and will not be covered moving 
forward. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover refraction. 
 
The services you asked the Plan to pre-approve are considered refraction. Therefore, we decided that the Plan 
does not have to pre-approve a refraction procedure for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network rheumatologist. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says medically necessary care is available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network rheumatologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a Primary Relief V1 electro-acupuncture device. 
 
You asked the Plan to pre-approve electro-acupuncture. You say that this device is a percutaneous nerve 
stimulator which differs from electro-acupuncture. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because this request if for an electro-acupuncture device which is not 
covered by Medicare under the circumstances. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the Primary Relief V1 device requested is considered 
to be an electro-acupuncture device and is not covered by Medicare. Therefore, we decided that the Plan does 
not have to pre-approve use of a Primary Relief V1 electro-acupuncture device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics, heel lift (L3310). 
 
You asked the Plan to pre-approve foot orthotics. You say that you are requesting an approval for a heal lift 
because your left leg is longer than your right leg. The Plan denied your request. The Plan says this item is not 
a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics, heel lift (L3310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested services exceed the maximum count allowed per period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers dentures once 
every five years. 
 
Dentures were last received on 4/18/17. This is less than five years ago. Based on this information, we decided 
that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a complete maxillary denture.