Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient office consult and treatments to be provided 
by an out of network (OON) provider to be covered at the in network benefits level. 
 
You asked the Plan to pre-approve the outpatient office visits. You say that this procedure is medically 
necessary for the treatment of your Parkinson's related essential tremor. The Plan denied your request. The Plan 
says there is no documentation from an in-plan movement disorder neurosurgeon that the requested service is a 
required treatment. The enrollee will need to use their out of network benefits to pursue treatment with the 
requested provider. 
 
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 
outpatient office consult and treatments to be provided by an out of network (OON) provider to be covered at 
the in network benefits level.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Radiofrequency ablation, nerves innervating the 
sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography). 
 
You asked the Plan to pre-approve Radiofrequency ablation, nerves innervating the sacroiliac joint, with image 
guidance (ie, fluoroscopy or computed tomography) (64625). You say that the enrollee has had this procedure 
and responded consistently getting significant pain relief. The Plan denied your request. The Plan says 
Radiofrequency ablation used for sacro-iliac joint pain is considered not medically necessary/investigational 
whether performed using traditional, cooled, or pulsed radiofrequency. 
 
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 Radiofrequency ablation, nerves 
innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) (64625). Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this is considered an experimental/ investigational procedure because of the wide 
variation in efficacy in the peer reviewed literature. Therefore, the request is considered not medically 
reasonable or 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 Radiofrequency ablation, nerves innervating the sacroiliac joint, with image 
guidance (ie, fluoroscopy or computed tomography) (64625) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Radiofrequency ablation, nerves innervating the sacroiliac joint, with image 
guidance (ie, fluoroscopy or computed tomography).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve these services. You say that your current oxygen equipment is too heavy. 
The Plan denied your request. The Plan says the item is not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a home oxygen concentrator and portable oxygen system. These items serve the 
same purpose as the requested portable oxygen concentrator. Therefore, we decided that the Plan does not have 
to pre-approve a portable oxygen concentrator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this is helpful for treatment of the health problem. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the Vertiflex device is experimental. More research is needed to show safety and efficacy. Also, there is 
no clear instability of the spine documented. The device is not medically needed. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the computed tomography (CT) scan of 
the abdomen, the CT scan of the thorax, and the low osmolar contrast material you received on March 24, 
2020. 
 
You asked the Plan to waive the cost sharing for the CT scans and materials. You say that you had these same 
services before and they were covered. The Plan denied your request. The Plan says you were charged this cost 
sharing 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 $160 
for each radiological diagnostic service (which includes CT scans), and you must pay 20% coinsurance for 
medical supplies.  
 
You have been asked to pay a total of $222.55 for the CT scans and contrast material.  You were charged a 
$160 copayment for the abdominal CT scan.  The allowable amount for the CT scan of the thorax was $60.15, 
which is less than your copayment.  As a result, you were charged the full $60.15 for this service.  You were 
charged 20% coinsurance for the contrast material used.  The allowable amount for the contrast material was 
$12.00, and 20% of that amount is $2.40.  Therefore, the total cost sharing owed is $222.55 ($160.00 + $60.15 
+ $2.40 = $222.55). 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 cost sharing for the computed tomography (CT) 
scan of the abdomen, the CT scan of the thorax, and the low osmolar contrast material you received on March 
24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown, a core buildup, including any pins when 
required, and a maxillary partial denture. 
 
You asked the Plan to pre-approve the crown, core buildup, and maxillary partial denture. You say that you 
need a new partial because your current one is broken. You have a really bad infection, which your face is 
swollen from, and you are struggling to eat. The Plan denied your request. The Plan says these services are not 
covered under 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, 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 
crown, a core buildup, including any pins when required, and a maxillary partial denture.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on April 7, 2020. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says the 
Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of 
election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers 
attending physician services and all care unrelated to the terminal illness until the first day of the month 
following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 6, 2020. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services 
provided on April 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist services. You say that you would like to see this doctor because 
you did not have success with the in-network provider. 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 
specialist services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crown (D2752) for tooth #3. 
 
You asked the Plan to pre-approve the crown (D2752) for tooth #3. You say that the current crown is infected 
and impacted with food. You say that the dentist will not perform the denture work until the crown is replaced. 
The Plan denied your request. The Plan says crowns are only covered one procedure per tooth every five plan 
years.  
 
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, you also have a maximum benefit of 
one crown per tooth every five plan years. The Plan paid for a crown for tooth #3 provided on March 12, 2018, 
which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the crown 
(D2752) for tooth #3.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bronchial thermoplasty. 
 
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 for pulmonary conditions. 
 
The Plan must follow Medicare rules. Medicare rules say that bronchial thermoplasty is not covered for 
pulmonary conditions.  
 
This is being requested for treatment of asthma. 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 
bronchial thermoplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (K0861, 
E2300, E0955, E2361, E1007, E1028, E2377, E2620, K0108 E2313, E2311). 
 
You asked the Plan to pre-approve the group 3 power wheelchair and accessories. You say that this chair is 
medically necessary. The Plan denied your request. The Plan says coverage criteria is not met, as the enrollee's 
mobility limitations are due to bilateral amputation and not due to one of the conditions listed in the criteria. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or 
congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 
power wheelchair and accessories (K0861, E2300, E0955, E2361, E1007, E1028, E2377, E2620, K0108 
E2313, E2311).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac contractility modulation system (0408T). 
 
You asked the Plan to pre-approve a cardiac contractility modulation system. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria has not been met. 
 
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 a cardiac contractility modulation 
system. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found in this circumstance treatment with the Optimizer System 
device has been demonstrated in only one trial to help reduce hospital readmission compared to standard 
medical therapy. Moreover, the trial was very small (only 160 patients) and the results for the composite 
endpoint barely reached statistical difference (p=0.048). Therefore, the efficacy of the Optimizer System is still 
uncertain at this time according to leading authorities and not recommended in current guidelines for the 
treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered 
experimental or investigational. 
 
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 cardiac contractility modulation system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a cardiac contractility modulation system (0408T).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan, brain 
imaging (78608). 
 
You asked the Plan to pre-approve a PET scan, brain imaging. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
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 a PET scan, brain imaging. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the notes describe no differential including frontotemporal dementia (FTD) 
vs. Alzheimer's disease therefore CMS does not cover FDG PET imaging unless such a differential exists. 
Furthermore, CMS will cover one Beta Amyloid PET scan provided the enrollee fulfills all clinical criteria for 
said scan and is involved in a CMS approved clinical trial which in this particular case does not apply. 
 
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 PET scan, brain imaging have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a positron emission tomography (PET) scan, brain imaging (78608).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electrical stimulation therapy. 
 
You asked the Plan to pre-approve electrical stimulation therapy. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
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 electrical stimulation therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is an experimental/ investigational therapy. Therefore, the request is 
deemed not medically reasonable or 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 electrical stimulation therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve electrical stimulation therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Trilogy ventilator for the enrollee. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the latest compliance report shows that the machine was only used two days. 
 
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 the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the enrollee 
may benefit from home BiPAP at night. The enrollee was started on a home ventilator for non-invasive 
ventilation after a hospitalization in May 2019. However, she has not been using the ventilator. A home 
ventilator is considered not medically necessary because Medicare does not cover a home ventilator when used 
as BiPAP, and the enrollee has not been using the device. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Trilogy ventilator for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pressure release mattress. 
 
You asked the Plan to pre-approve the mattress. You say that the mattress is medically necessary. The Plan 
denied your request. The Plan says this item is not covered. 
 
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 pressure release mattress.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant (D6010) for tooth 
#29. 
 
You asked the Plan to pre-approve the surgical placement of implant (D6010). You say that the cap had fallen 
out a few weeks before seeing the dentist. You say that part of the bill should be covered. The Plan denied your 
request. The Plan says the service 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 the 
surgical placement of implant (D6010) for tooth #29.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation. 
 
You asked the Plan to pre-approve the routine transportation services. You say that your provider referred you 
to a specialist because you have had several surgeries and because this specialist would be 
best person to treat you. You say that you have no other way of getting there. You say that you were in a car 
accident and that your car was totaled. The Plan denied your request. The Plan says the rules for coverage have 
not been met. 
 
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 Plan's coverage rules apply in this 
case. The Plan covers routine transportation when each trip does not exceed 50 miles.  
 
We looked at your request, the records in the case file, and the rules. The records show that you are requesting 
transportation to a destination that is 341 miles from your home address. Based on this information, we decided 
that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve routine transportation.