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

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve the continued SNF care. You say that although you are making progress, 
you do not feel that you are ready to go home. The Plan denied your request. The Plan says your condition has 
improved since your admission. The Plan also says that you could now be safe at a lower level of care with 
caregivers. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 the continued SNF care. Our reviewer 
says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have 
daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, 
these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of 
the continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve 
continued SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the power scooter. You say that you would like reconsideration because the 
scooter is not meant to be used in your home so a home evaluation is not necessary. The Plan denied your 
request. The Plan says a face-to-face assessment from the provider is needed to proceed with processing this 
request. 
 
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. Additionally, in order for this equipment to 
be approved, there must be a written report of a face-to-face home evaluation. Therefore, we decided that the 
Plan does not have to pre-approve a power scooter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services you had on April 27, 2020. 
 
You asked the Plan to waive the copayment for the lab services. You say that you normally would have gone to 
your regular lab but it was closed due to COVID-19. The Plan denied your request. The Plan says you were 
charged the correct cost sharing. 
 
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 $40 
copayment for lab services provided in an outpatient hospital facility.  
 
You have been asked to pay a $40 copayment for the lab services provided in an outpatient hospital facility 
benefit category. Your Evidence of Coverage explicitly states that you pay a $40 copayment for labs you 
receive in an outpatient hospital facility. This cost sharing applies regardless of the reason why you went to the 
facility. 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 lab services you had on April 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient mammogram provided on December 26, 2019 
by an out of network (OON) provider. 
 
You asked the Plan to pay for an outpatient mammogram. You say that this was preventative and therefore, 
should be covered. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an outpatient mammogram provided on December 
26, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wheelchair provided on May 12, 2019 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for durable medical equipment. You say that you would like this claim reprocessed 
and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
there are in-network providers available for these services. 
 
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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a wheelchair provided on May 12, 2019 by an out 
of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings (D0274) provided on June 10, 2020. 
 
You asked the Plan to pay for the bitewings. The Plan denied your request. The Plan says this service is not a 
covered by your dental 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 pay for the 
bitewings (D0274) provided on June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a collection of blood sample (36415) 
performed on February 7, 2020. 
 
You asked the Plan to waive the coinsurance for a collection of blood sample. You say that you were told 
erroneously that your doctor was in-network. The Plan denied your request. The Plan says the correct 
coinsurance 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 30% 
coinsurance for Medicare-covered diagnostic procedures and tests, lab services, blood services, diagnostic and 
nuclear medicine radiological services, therapeutic radiology services, and X-rays.  
 
You have been asked to pay $0.90, or 30% of the Plan-allowed amount of $3.00, for a collection of blood 
sample. A collection of blood sample falls within the "Outpatient diagnostic tests and therapeutic services and 
supplies" 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 a collection of blood 
sample (36415) performed on February 7, 2020.  
 
 
 
Your complaint about receiving erroneous or misleading information about the network status of your primary 
care provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pneumatic compressor, segmental home model with 
calibrated gradient pressure (CPT Code E0652) and segmental pneumatic appliance for use with pneumatic 
compressor, full leg (CPT Code E0667). 
 
You asked the Plan to pay for the DME. You say that the DME is medically necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
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 DME. Our physician reviewer found the 
review has determined that the enrollee does not meet criteria for advance pump because he did not fail a four-
week trial of daily, regular, multiple-hour home usage of E0650 or E0651. The records include documentation 
of over 90 days of failed conservative treatment, but there are no measurements submitted. A trial of the basic 
pump was not ordered. The provider documents that the risk of truncal swelling and concerns regarding 
existing pain levels precluded the use of static pressures applied by the basic pump. In addition, it is not clear if 
member had a successful in office trial of the advanced PCD. The review has determined that the medical 
records provided did not meet the requirements listed in the LCD/NCD for Medicare coverage for pneumatic 
compressor, segmental home model with calibrated gradient pressure (CPT Code E0652) and segmental 
pneumatic appliance for use with pneumatic compressor, full leg (CPT Code E0667). 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pay for pneumatic compressor, segmental home model with calibrated gradient pressure (CPT Code E0652) 
and segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT Code E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ensure nutritional supplements. 
 
You asked the Plan to pre-approve nutritional supplements. You say that you feel you need this supplement to 
continue being healthy. The Plan denied your request. The Plan says the denial of authorization for these 
supplies is correct, because these nutritional supplements are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan 
does not have to pre-approve Ensure nutritional supplements.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve echocardiography, transthoracic, real-time with image 
documentation (2D), includes M-mode recording, when performed, complete, without spectral or color 
Doppler echocardiography (CPT Code 93307). 
 
You asked the Plan to pre-approve the services. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that the service is not 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 services. Our physician reviewer 
found the patient had an isolated dilated aortic root of 4.1 cm. Anything greater than 4.0 cm warrants yearly 
surveillance with imaging, which applies to this patient. Based on the documentation, it has been one year since 
the prior echocardiogram. Interpreting the LCD for Medicare coverage, it does not specify any particular 
interval of surveillance for this clinical situation, but does support surveillance. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode 
recording, when performed, complete, without spectral or color Doppler echocardiography (CPT Code 93307).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MYO Pro Motion G Orthotic device (a powered 
upper extremity range of motion assist device) (L8702). 
 
You asked the Plan to pre-approve the device. You say that the claim should be paid. The Plan denied your 
request. The Plan says this is not a covered item since it is experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our 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 
items/services are not considered medically reasonable and necessary in this case. Our reviewer found a review 
of the literature indicates that this service is considered experimental and 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an MYO Pro Motion G Orthotic device (a powered upper extremity range of motion assist 
device) (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home ventilator, any type, used with non-invasive 
interface, (e.g., mask, chest shell) (CPT Code E0466). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
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 DME. Our physician reviewer 
found the coverage criteria for a home ventilator are not met. The patient has severe chronic obstructive 
pulmonary disease (COPD) with frequent hospitalizations for acute-on chronic hypercarbic and hypoxic 
respiratory failure. The patient improves in the hospital on BiPAP, but it appears BiPAP has not been tried at 
home. There is no documented failure of BiPAP to maintain oxygenation and prevent hypoventilation with the 
patient in a stable state at home. Some BiPAP devices are capable of providing the AVAPS-AE mode of 
support that has been ordered. Medicare does not cover a ventilator when used as BiPAP. In addition, the 
patient is suspected of having obstructive sleep apnea. A home ventilator is not medically necessary, and the 
denial is upheld. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) (CPT Code 
E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that this is necessary due to the enrollee's 
severe pathology. The Plan denied your request. The Plan says the enrollee did not receive sufficient pain relief 
from MBBs. 
 
The Plan must follow Medicare rules. Medicare rules say that only when dual MBBs provide at least 80% relief 
of the primary or index pain and duration of relief is consistent with the agent employed may facet joint 
denervation with radiofrequency medial branch neurotomy be considered. 
 
We looked at the file and Medicare rules. The record shows that MBBs provided only 70% pain relief for the 
enrollee. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation 
have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the extraction (D7210) of tooth #11. 
 
You asked the Plan to pre-approve the extraction. The Plan denied your request. The Plan says that the 
documentation does not support the surgical extraction (D7210) of tooth #11. 
 
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 extraction 
of tooth #11 when the services are medically necessary and reasonable. 
 
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 extraction of tooth #11. Our 
reviewer says that the extraction (D7210) of tooth #11 meets criteria. Our physician reviewer found tooth #11 
had a prior crown, which has left a tapered coronal structure, thus compromising the ability to properly utilize a 
forceps, and supporting the need for a surgical removal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the extraction of tooth #11 have been met. Therefore, we decided that the Plan 
has to pre-approve the extraction (D7210) of tooth #11.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of oxygen for treatment of cluster headaches. 
 
You asked the Plan to pre-approve oxygen. You say that this treatment has been effective for the enrollee. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because this 
service is not covered by Medicare except in an approved clinical study. 
 
The Plan must follow Medicare rules. Medicare rules say that home use of oxygen to treat cluster headache is 
not covered except in the context of an approved clinical study.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of oxygen have not been met. Therefore, we decided that the Plan does not have to pre-approve use of 
oxygen for treatment of cluster headaches.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three office visits for the requested physician's services. 
 
You asked the Plan to pre-approve the three office visits. You say that you were granted one visit however, 
based on many office visits the first appointment is just gathering information and you will need three visits. 
The Plan denied your request. The Plan says your needs can be met within your health plan network and you 
would not meet criteria for a referral at this time. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve three 
office visits for the requested physician's services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an over the bed table (E0274). 
 
You asked the Plan to pre-approve an over the bed table (E0274). You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says this item is not covered by Medicare or the 
Plan. 
 
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 over the bed table (E0274).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PET imaging with concurrently acquired CT. 
 
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 imaging. Our reviewer says that the 
requested imaging is not medically reasonable or necessary. Our physician reviewer found the requesting 
physician has provided multiple literature references which shows some value of FDG-18 PET/CT in the 
monitoring of GCA.  However, the data is preliminary with many of these articles suggesting that further 
investigation is necessary including long term follow-up. The CMS criteria for medical necessity for PET/CT 
does not recognize the use of PET/CT to monitor GCA and considers the technique 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 the imaging have not been met. Therefore, we decided that the Plan does not 
have to pre-approve PET imaging with concurrently acquired CT.