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

 
We decided that the Plan does not have to pay for CxBladder genetic testing (0012M) provided on July 16, 
2020. 
 
You asked the Plan to pay for CxBladder genetic testing. You say that this is a covered service. 
 The Plan denied your request. The Plan says this was a screening test. 
 
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 pay for CxBladder genetic testing. Our reviewer 
says that the services at issue are not considered medically reasonable and necessary in this case. Our physician 
reviewer found CxBladder is not a screening test for urothelial cancer in patients with hematuria. Cystoscopy 
and possible biopsy and upper tract imaging will still be necessary regardless of the results of Cxbladder 
testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CxBladder genetic testing have not been met. Therefore, we decided that the 
Plan does not have to pay for CxBladder genetic testing (0012M) provided on July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pain management services (J1100, J7042, 64484, 
64483) to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve OON pain management services. You say that you've been paying for these 
services out-of-pocket and they are medically necessary. The Plan denied your request. The Plan says 
medically necessary services are 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 
the pain management services (J1100, J7042, 64484, 64483) to be provided by an out of network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medical alert system. 
 
You asked the Plan to pre-approve medical alert system. You say that you need this device because of your 
conditions, and you live alone. The Plan denied your request. The Plan says the denial of authorization for this 
device is correct, because an alert system is precautionary and not medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a medical alert system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extractions of erupted teeth (D7210). 
 
You asked the Plan to pre-approve the extractions of erupted teeth. You say that these services are not for 
cosmetic purposes and are medically necessary. The Plan denied your request. The Plan says you have 
exhausted your benefit for this service. 
 
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 the 
extractions of erupted teeth when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. In this case, the file indicates that one extraction of erupted tooth has 
previously been approved for coverage. Therefore, your benefit limit has been exhausted. Any additional teeth 
extraction services will not be covered by the Plan. Based on this information, we decided that the Plan's rules 
for coverage of the extractions of erupted teeth have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the extractions of erupted teeth (D7210).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the co payment for an inpatient hospital stay provided. 
 
You asked the Plan to waive the co payment for an inpatient hospital stay. You say that you disagree with the 
charges because you had no say as to which hospital the ambulance would take the enrollee.  The Plan denied 
your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct 
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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $250 copayment per admission, for hospital inpatient care.  
 
The enrollee has been asked to pay a $250 copayment for an inpatient hospital stay. An inpatient hospital stay 
falls within the hospital inpatient care benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an inpatient hospital stay provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical procedure provided. 
 
You asked the Plan to pay for the orthovisc knee injections. You say that you paid the provider $500. The Plan 
denied your request. The Plan says your copayment is $55.94 and you will have to contact the provider for a 
refund. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
You have been asked to pay $55.94 for the orthovisc knee injections. The orthovisc knee injections fall within 
the Outpatient Surgery and Part B drug benefit category. The allowable charges for the injections totaled less 
than $25 each so your copayments are less. 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 for the medical procedure 
provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that this is medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day and use insulin with at least three daily injections. Based on this 
information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor 
(CGM).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services (G0162, G0299). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that you do not meet criteria for coverage of home 
health skilled nursing services as the record does not show that you are home bound. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be 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 home health skilled nursing services. 
Our reviewer says that the home health skilled nursing services requested are not medically necessary. Our 
physician reviewer found that in order to require home health skilled services, you must be confined to the 
home, under the care of a physician, and receiving services under a plan of care established and periodically 
reviewed by a physician. Additionally, you must be in need of skilled nursing care on an intermittent basis or 
physical therapy or speech-language pathology; or have a continuing need for occupational therapy. Being 
homebound means leaving home is a major effort. In this case, the documentation doesn't support that you 
require skilled nursing services or skilled rehabilitation services to provide treatment in the home that is 
medically necessary. You do not require in home skilled nursing or rehabilitation services to effectively 
provide treatment, care, and/or services in order to improve your condition or perform a maintenance program 
to maintain your condition and/or prevent deterioration. You have been medically stable without any recent 
exacerbations of chronic medical problems or hospitalizations. The documentation does not support that you 
are home bound, therefore the services 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health skilled nursing services (G0162, G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high speed motor option for a power wheelchair. 
 
You asked the Plan to pre-approve the requested item. You say that it would allow you to quickly navigate 
roadways to attain essential services. The Plan denied your request. The Plan says the request is not a covered 
option. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a high speed motor option for a power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has not failed oral and intravenous bisphosphonates. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the 
criteria for coverage of Prolia have not been met. Our physician reviewer found there is no documentation of 
trial and failure or inability to take first line oral or IV bisphosphonate therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ketamine infusions. 
 
You asked the Plan to pre-approve Ketamine infusions. You say that the enrollee suffers from a spinal cord 
injury and associated pain. You also say that the enrollee has tried a comprehensive multidisciplinary treatment 
plan for his pain with minimal success. The Plan denied your request. The Plan says that Ketamine is not 
indicated by the FDA for the treatment of chronic pain. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Ketamine infusions. Our reviewer says 
that the Ketamine infusions are not medically necessary. Our physician reviewer found the requested use of 
Ketamine infusions are not FDA-approved for the enrollee's diagnosis. The reviewer found that the use of 
Ketamine for chronic pain is not supported by one of the major drug compendia or by clinical research that 
appears in a CMS-approved medical journal. Therefore, the reviewer found that the Ketamine infusions 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 Ketamine infusions have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Ketamine infusions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ice pack. 
 
You asked the Plan to pre-approve the ice pack. You say that this helps bring down your swelling. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an ice pack.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the member would be at great risk for a fall if she is 
at home. The Plan denied your request. The Plan says that you can safely receive the services you need in other 
settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a stroke. The 
enrollees medical conditions are stable. There are no medical needs requiring inpatient admission. There are 
no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record documents a need for physical and occupational therapy, it does not document a need 
for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
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 this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says that dentures are covered once every five years. Your 
request exceeds the allowable coverage for this item as you received a partial denture less than five years ago.  
 
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.  
 
We looked at the case file and the Plans rules. Based on this information, we decided that the Plan's rules for 
coverage of this item have not been met. Specifically, dentures are covered once every five years. The record 
shows that you previously received a lower partial denture on January 15, 2018, which was less than five years 
ago. Therefore, we decided that the Plan does not have to pre-approve a lower partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the limited oral evaluation (D0140) and the 
comprehensive oral evaluation (D0150) provided on March 19, 2020 and April 9, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the limited oral evaluation is not a covered 
benefit under your dental policy. Additionally, the comprehensive oral evaluation is not covered as it was 
provided by an out of network provider.  
 
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 limited oral evaluation provided is 
not among those covered under this benefit. Additionally, the comprehensive oral evaluation is not covered by 
the Plan as it was rendered by an out of network provider. Therefore, we decided that the Plan does not have to 
issue reimbursement for the limited oral evaluation (D0140) and the comprehensive oral evaluation (D0150) 
provided on March 19, 2020 and April 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crown - porcelain fused to high noble metal (D2750) 
and core buildup (D2950). 
 
You asked the Plan to pre-approve the crown - porcelain fused to high noble metal and core buildup. You say 
that these services are medically necessary for enrollee's condition. The Plan denied your request. The Plan 
says these services are not covered under the enrollee's benefit plan. 
 
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 the 
crown - porcelain fused to high noble metal (D2750) and core buildup (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473) and non-
intravenous conscious sedation (D9248). 
 
You asked the Plan to pre-approve the removal of torus mandibularis and non-intravenous conscious sedation. 
You say that these services are medically necessary due to your condition. The Plan denied your request. The 
Plan says these services are not covered under your benefit package. 
 
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 the 
removal of torus mandibularis (D7473) and non-intravenous conscious sedation (D9248).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
August 28, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you were uncertain about the 
treatment you were getting from your previous provider, and made an appointment to see a new dentist. The 
Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan. 
 
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, comprehensive oral evaluation 
(D0150) is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on November 19, 2019, and your comprehensive oral evaluation 
(D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150) provided on August 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder testing rendered on January 15, 2020. 
 
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 the testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that the CxBladder testing is non-covered. 
 
The test at issue is CxBladder. This test is not covered by Medicare. 
 Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on January 15, 
2020.