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

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed and dry pressure mattress. 
 
You asked the Plan to pre-approve a semi-electric hospital bed and dry pressure mattress. You say that the 
requested semi-electric hospital bed and dry pressure mattress are medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for the requested semi-electric hospital bed and dry 
pressure mattress. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or  
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position.  
 
The rules also say a Group 1 mattress overlay or mattress is covered if one of the following three criteria are 
met: 
 
1. The beneficiary is completely immobile - i.e., beneficiary cannot make changes in body position 
without assistance, or 
2. The beneficiary has limited mobility - i.e., beneficiary cannot independently make changes in body 
position significant enough to alleviate pressure and at least one of conditions A-D below, or 
3. The beneficiary has any stage pressure ulcer on the trunk or pelvis and at least one of conditions A-D 
below. 
 
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 semi-electric hospital bed and dry 
pressure mattress. Our reviewer says that the enrollee does not meet criteria for the requested semi-electric 
hospital bed and dry pressure mattress. Our physician reviewer found the enrollee is with a past medical history 
of type II diabetes, chronic kidney disease, hypothyroidism, abnormality of gait and mobility and weakness.  
 
Based on the medical records provided there is no documentation that the enrollee's condition requires position 
of the body in ways not feasible in an ordinary bed. There is no documentation that the enrollee requires 
frequent changes in body position or immediate changes in body position. There is no documentation that the 
enrollee's condition requires special attachments that cannot be fixed and used on an ordinary bed. There is no 
documentation that a semi-electric hospital bed is medically necessary for this enrollee. There is no 
documentation that the enrollee meets Medicare coverage criteria for the requested dry pressure mattress.  
 
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 semi-electric hospital bed and dry pressure mattress have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed and dry pressure 
mattress.
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 4, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that the treating provider requires all 
new patients to be given a comprehensive oral evaluation. You also say that since a periodic oral exam is 
covered under your dental plan, you feel the plan should allow that amount towards payment of what you were 
charged for the comprehensive oral evaluation. 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) and is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on July 24, 2018, 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 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you are in pain and unable to walk. 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.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the diagnostic ultrasound provided on July 1, 2020. 
 
You asked the Plan to pay for the diagnostic ultrasound. The Plan denied your request. The Plan says that the 
facility lacks site certification. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided us with any valid rationale to support the denial of 
payment for these services. Therefore, we decided that the Plan has to pay for a diagnostic ultrasound provided 
on July 1, 2020.  
 
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 9, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 9, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on July 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive periodontal evaluation (D0180), drugs 
and/or medicaments dispensed in the office for home use (D9630), periodontal scaling and root planing of the 
upper and lower left quadrant (D4341), the unspecified periodontal procedure (D4999), and the unspecified 
adjunctive procedure (D9999). 
 
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 the services requested are not a covered benefit 
under your contractual policy. Additionally, scaling and root planing of the upper and lower left quadrant is a 
covered benefit; however, your request exceeds the frequency allowable 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Additionally, your request for periodontal scaling and root planing (D4341) of 
the upper and lower left quadrant does not meet criteria for coverage as you previously received this service on 
January 4, 2019. The Plan provides coverage of this service once every twenty four months. Therefore, we 
decided that the Plan does not have to pre-approve a comprehensive periodontal evaluation (D0180), drugs 
and/or medicaments dispensed in the office for home use (D9630), periodontal scaling and root planing of the 
 
 
upper and lower left quadrant (D4341), the unspecified periodontal procedure (D4999), and the unspecified 
adjunctive procedure (D9999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown provided on January 28, 2020. 
 
You asked the Plan to pay more for the crown. You say that you your benefit should not be exhausted. The 
Plan denied your request. The Plan says the Plan has paid a total of $2,000 toward your dental services since 
January 1, 2020. The Plan also says that the remaining amount of $191.00 is your responsibility. 
 
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 Plan offers a $2,000 annual 
allowance for supplemental preventive and comprehensive services. The contract says that you are responsible 
for any amount over and above the allowance amount. The record shows that you met the annual maximum 
benefit while processing this claim for the January 28, 2020 date of service, and your annual maximum benefit 
has been exhausted. Therefore, we decided that the Plan does not have to pay more for the crown provided on 
January 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator 
provided on July 21, 2020, and August 21, 2020. 
 
You asked the Plan to waive the coinsurance for an automatic external defibrillator. You say that you disagree 
with the charges because you were not told of the high cost. The Plan denied your request. The Plan says the 
claims were processed correctly and you are 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). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for DME and related supplies.  
 
You received an automatic external defibrillator on July 21, 2020. The allowed amount is $2,925.60 and 20% 
of that is $585.12.  
 
You received an automatic external defibrillator on August 21, 2020. The allowed amount is $2,925.60 and 
20% of that is $585.12. 
 
The total amount you owe is: $1,170.24. 
 
You have been asked to pay the total coinsurance amount of $1,170.24 for an automatic external defibrillator. 
An automatic external defibrillator falls within the DME and related 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 an automatic external defibrillator provided on July 21, 2020, and 
August 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cone beam CT capture and interpretation with limited 
field of view - less than one whole jaw (D0364). 
 
You asked the Plan to pre-approve the dental services. You say that the service is necessary. The Plan denied 
your request. The Plan says the service is not a covered benefit under the 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. This service is not listed in your handbook as a covered benefit; 
therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve cone beam CT 
capture and interpretation with limited field of view - less than one whole jaw (D0364).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for MRI of the chest spine (72157) and MRI of the lumbar spine 
(72158) provided on July 9, 2020. 
 
You asked the Plan to pay for the MRI. You say that you would like reconsideration because this service was 
billed with the appropriate place of service. The Plan denied your request. The Plan says this claim was billed 
with an outpatient place of service code, but the member was inpatient from July 5, 2020, through July 23, 
2020. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, 
shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient 
actually receives the face-to-face encounter. 
 
We find that CPT codes 72157 and 72518 are not supported in the record. Specifically, this claim was billed 
with an outpatient place of service code. The record indicates that the member was registered inpatient on the 
billed date of service. Based on this information, we decided that Medicare rules for coverage of the MRI have 
not been met. Therefore, we decided that the Plan does not have to pay for MRI of the chest spine (72157) and 
MRI of the lumbar spine (72158) provided on July 9, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital care provided from June 8, 2020, to June 10, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the inpatient care provided was 
medically necessary. The Plan denied your request. The Plan says that prior authorization was not obtained 
once the enrollee's emergency medical condition had stabilized. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 inpatient hospital care. Our reviewer 
says that the services provided were medically necessary and reasonable in this case. Our physician reviewer 
found there were metabolic abnormalities that needed to be corrected along with transfusion prior to patient 
being deemed stable. Therefore, the facility treated the patient appropriately within the reasonable range 
regarding transferring the patient in a timely/acceptable fashion after being stable. Excessive post-stabilization 
care was not administered. 
 
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 inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the inpatient hospital care provided from June 8, 2020, to June 10, 2020 by an out of network 
(OON) provider.  
 
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: Favorable

 
We decided that the Plan has to pre-approve XTRAC laser treatment. 
 
You asked the Plan to pre-approve the treatment. You say that this is medically necessary to cure your hands 
and face. The Plan denied your request. The Plan says that this is considered cosmetic. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 treatment. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found laser treatment of vitiligo is considered a standard of 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 the treatment have been met. Therefore, we decided that the Plan has to pre-
approve XTRAC laser treatment.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine rendered on September 9, 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 services are not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to these services. 
Therefore, we decided that the Plan does not have to pay for the shingles vaccine rendered on September 9, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cranial vagus nerve stimulator array and pulse 
generator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that vagus nerve stimulation for the treatment of 
depression when offered in a CMS-approved, double-blind, randomized, placebo-controlled trial. 
 
We looked at the file and Medicare rules. The services are not being requested in conjunction with a CMS-
approved trial. 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 a cranial vagus nerve 
stimulator array and pulse generator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 16, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because the
services rendered were medically necessary and provided in good faith. The Plan denied your request. The Plan
says services rendered by non-contract 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 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 the medical services provided on July 16, 2020 by
an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on May 5, 2020 and 
billed under codes 80074 and 87507. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says this service was ordered as a screening and is not covered by Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. These services were requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
lab services provided to the enrollee on May 5, 2020 and billed under codes 80074 and 87507.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a PWC is covered when specific criteria are 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 pre-approve these services. Our reviewer says that 
the enrollee does not meet the criteria for coverage. Our physician reviewer found the enrollee has a mobility 
limitation but there is no recent detailed evaluation indicating how this affects his ability to participate in one or 
more mobility-related activities of daily living (MRADLs) in the home. There is no recent detailed 
neuromuscular exam of the upper and lower extremities or evaluation of whether this mobility exam can be 
helped by an appropriately fitted manual wheelchair. The documentation is not clear that the enrollee can safely 
and adequately maneuver this device in the home. The enrollee does not meet the criteria for coverage and the 
services are 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 a replacement power wheelchair (PWC).