Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of an impacted, completely bony, tooth 
(D7240) for teeth # 16 and 17, and the removal of an impacted, partially bony, tooth (D7230) for tooth # 32. 
 
You asked the Plan to pre-approve the dental services. You say that these services were approved last year 
under the enrollee's plan. You say that the enrollee is in pain. You also say that the enrollee needs to have their 
wisdom teeth extracted. The Plan denied your request. The Plan says the removal of an impacted tooth, 
completely bony, is not listed as a covered service. The Plan says the removal of an impacted tooth, partially 
bony, is not listed as a covered service either. 
 
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. The Evidence of Coverage clearly states that any services not listed are not 
covered. Therefore, we decided that the Plan does not have to pre-approve the removal of an impacted, 
completely bony, tooth (D7240) for teeth # 16 and 17, and the removal of an impacted, partially bony, tooth 
(D7230) for tooth # 32.
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 disagree with the denial. The Plan denied 
your request. The Plan says the enrollee does not have a condition for which the services are covered. 
 
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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the finger splint to be provided by a non-Medicare 
provider. 
 
You asked the Plan to pre-approve the finger splint. You say that this is the only company that makes custom 
sized ring splints out of silver. The Plan denied your request. The Plan says the Medicare rules have not been 
met. 
 
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. 
 
This provider does not participate with Medicare and is not in-network with your Plan. Medicare guidance says 
to receive payment for covered Medicare items or services from either Medicare (in the case of an assigned 
claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or supplier must be enrolled 
in the Medicare program. 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 finger splint to be provided by a non-Medicare provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the implantable neurostimulator pulse generator (L8679). 
 
You asked the Plan to pre-approve the implantable neurostimulator pulse generator. You say that the 
neurostimulator will aid in the enrollee's ability to participate in normal activities of daily living, including job 
duties. The Plan denied your request. The Plan says that this device/procedure is considered investigational. 
 
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. In this case, required information (the Evidence of Coverage) was missing from 
the case file. A request for information was sent to the health plan on September 14, 2020, with a due date of 
September 17, 2020, and a second request was sent on September 24, 2020, with a due date of September 28, 
2020. As of the date of this letter, the plan has not responded to our request and/or submitted the required 
information. Therefore, we decided that the Plan has to pre-approve the implantable neurostimulator pulse 
generator (L8679).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PSG; age 6 years or older, sleep staging with 4 or 
more additional parameters of sleep, attended by a technologist (CPT Code 95810). 
 
You asked the Plan to pre-approve the PSG. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not 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 PSG. Our physician reviewer found 
coverage criteria for an attended diagnostic PSG are not met. There is no documentation of whether the patient 
has observed apneas, no quantification of daytime sleepiness, and no detailed upper airway examination. There 
are also no contraindications to a home sleep study, such as significant heart failure, chronic obstructive 
pulmonary disease (COPD), body mass index (BMI), greater than 45. A home sleep study would be a 
reasonable screening test. An attended PSG is 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 the PSG have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the PSG; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, 
attended by a technologist (CPT Code 95810).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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. Our 
physician reviewer found based on the documentation provided, the health plan's denial should be upheld. The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee;s care 
needs can be met at a lower level 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro 2 arm orthosis. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records show that you 
have muscle weakness/partial paralysis (hemiparesis) in your left arm. You are unable to bear weight on your 
left arm and it interferes with routine activities. The requested robotic orthosis is not proven to be more 
beneficial for treatment of your medical condition after stroke than any available standard therapy. The 
requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to 
improve the functioning of a malformed body member. 
 
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 MyoPro 2 arm orthosis.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services you received on 
February 20, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that these services were 
needed on an emergency basis.  You also stated that you weren't sent a bill for these services for over five 
months. The Plan denied your request. The Plan says you were charged this copayment 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 $240 
copayment for ambulance services.  
 
You have been asked to pay a $240 copayment for the ambulance services. This copayment applies regardless 
of whether or not the services were emergent. 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 the 
ambulance services you received on February 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coronary computed tomography angiography (CCTA) 
with calcium evaluation. 
 
You asked the Plan to pre-approve these services. You say that this should be covered. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CCTA 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 services are not medically necessary. Our physician reviewer found the submitted records show that you 
have high concentration of fats/lipids in the blood (hyperlipidemia) but no other cardiovascular risk factors. A 
prior CT calcium score in 2013 was low and a stress cardiac nuclear study in 2016 was normal. You have no 
documented cardiac symptoms, even with vigorous activity. The services do not meet the Medicare criteria for 
coverage and 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 coronary computed tomography angiography (CCTA) with calcium evaluation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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. Our 
physician reviewer found the complexity of the patient's nursing, medical, and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The patient 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the patient's functional status requires or can tolerate an intensive rehabilitation therapy program 
provided in an IRF. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SmartVest Airway Clearance System for the 
enrollee. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says diagnoses of COPD or chronic bronchitis without bronchiectasis are not covered 
conditions. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 system. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found severe COPD is 
not a covered diagnosis. There is no convincing evidence that this device helps with COPD. The enrollee does 
not have bronchiectasis or any other covered diagnosis. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the SmartVest Airway Clearance System for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug infusion pump supplies rendered on March 26, 
2020, to April 22, 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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the drug infusion pump supplies rendered on March 26, 2020, 
to April 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient admission for plastic surgery 
 
You asked the Plan to pay for acute inpatient hospital care. You say that due to multiple comorbidities, the 
enrollee would need to be inpatient for wound care and IV antibiotics. The Plan denied your request. The Plan 
says inpatient admission is not needed. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the surgeon states "If surgery can only be authorized as 23 hour observation, I am 
agreeable to that as well." The documentation does not support that inpatient admission is medically reasonable 
and necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient admission for plastic surgery
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the special power wheelchair and accessories. 
 
You asked the Plan to pre-approve the special power wheelchair and accessories. You say that you have been 
waiting for several months now for your power wheelchair. The Plan denied your request. The Plan says the 
Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the special power wheelchair and accessories have not been met. 
Medicare criteria are not met for a replacement Group 3 Power Wheelchair as you currently have a Group 3 
Power Wheelchair that is less than 5 years old. Per Medicare rules, replacement due to wear is not covered 
during the reasonable useful lifetime of the equipment (less than 5 years). Therefore, we decided that the Plan 
does not have to pre-approve the special power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the fluoroscopic guided injection you 
received from a specialist on March 25, 2020. 
 
You asked the Plan to waive the copayment for the fluoroscopic guided injection with a specialist. You say that 
you wished to appeal this charge. The Plan denied your request. The Plan says you were charged this 
copayment 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 $50 
copayment for services with a specialist.  
 
You have been asked to pay a $50 copayment for the fluoroscopic guided injection with a specialist. 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 the fluoroscopic guided injection you received from a 
specialist on March 25, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED visit. 
 
You asked the Plan to pay for the ED visit. You say that the enrollee was not enrolled in hospice on this date of 
service. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of 
all Medicare covered services related or unrelated to the enrollee's terminal condition. 
 
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. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the ED visit.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the MRI, spinal canal and contents, lumbar; without contrast 
material (CPT Code 72148). 
 
You asked the Plan to pre-approve the MRI. You say that the service is necessary. The Plan denied your 
request. The Plan says that the service is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our physician reviewer found 
that with radicular symptoms it is indicated to get MRI to assess the severity of the condition to advise for 
intervention. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
the MRI, spinal canal and contents, lumbar; without contrast material (CPT Code 72148).  
 
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.