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

 
We decided that the Plan does not have to pay for the addition of tooth to an existing partial denture and third 
amalgam provided on May 12, 2020, and May 16, 2020. 
 
You asked the Plan to pay for the addition of tooth to an existing partial denture and third amalgam. You say 
that the Plan advised you that about $450 worth of the services would be covered. The Plan denied your 
request. The Plan says addition of tooth to an existing partial denture is not a covered benefit. The Plan also 
says that benefits for the third amalgam have been satisfied and the frequency limitation has been exceeded. 
 
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, addition of tooth to an existing partial 
denture is not among those covered under this benefit. The contract also clearly states that restorations are 
limited to two procedures per calendar year. The record shows that you received amalgams on May 20, 2020 
and June 26, 2020, and your restorations benefit has been exhausted. Therefore, we decided that the Plan does 
not have to pay for the addition of tooth to an existing partial denture and third amalgam provided on May 12, 
2020, and May 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex superion spacer device, insertion of 
interlaminar/interspinous process stabilization/distraction device (22869, 22870). 
 
You asked the Plan to pre-approve the Vertiflex superion spacer device. You say that if Medicare has approved 
this procedure this 2006 so the plan has no right to deny it. You are having difficulty walking. You've had 
physical therapy and nothing seems to work. The Plan denied your request. The Plan says there is a lack of 
evidence to support that interspinous spacer devices are safe and effective as the gold standard of 
decompression. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex superion spacer device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Vertiflex superion spacer device, insertion of interlaminar/interspinous process 
stabilization/distraction device (22869, 22870).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on July 10, 2020. 
 
You asked the Plan to pay for the services provided. You say that the medical records support medical 
necessity. The Plan denied your request. The Plan says to report comprehensive genomic profile testing, 
service providers should use CPT code 81479. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
The documentation shows that the enrollee received a pharmacogenomics panel. We looked at the file and the 
rules. If one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the 
lab shall report only one unit of service. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing 
services provided on July 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on July 10, 2020. 
 
You asked the Plan to pay for the testing. You say that you would like reconsideration because this testing is 
medically necessary. The Plan denied your request. The Plan says to report a CGP, service providers should 
use CPT code 81479 in addition to the approved DEX Z-CodeTM; not unbundled, separate codes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, the testing, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. The documentation does not show that the requested 
pharmacogenomic testing was ordered due to any signs/symptoms of a drug reaction. There is no evidence that 
the testing was provided for therapeutic decision-making regarding the need for the use of any specific drug. 
This means that this extended panel was provided for screening purposes, and this type of testing is not among 
 
 
those covered by Medicare for screening. Therefore, we decided that the Plan does not have to pay for genetic 
testing provided on July 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of mini implants (D6013) for teeth 
22, 24, 26 and 28. 
 
You asked the Plan to pre-approve the dental implants. You say that the enrollee had a denture made that was 
unacceptable due to lack of retention. He has facial tremors that dislodge the denture. The obvious solution is 
to place mini implants to retain the denture. The Plan denied your request. The Plan says this service is not 
covered under the plan benefits. 
 
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. Services not listed as a 
covered dental procedure are not covered by the plan. 
 
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 
surgical placement of mini implants (D6013) for teeth 22, 24, 26 and 28.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs HF System. 
 
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 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 herapy change based on data obtained 
from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission 
compared to standard medical therapy. The efficacy of the device is uncertain at this time and use is considered 
experimental/investigational in nature. The services are therefore 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 CardioMEMs HF System.  
 
Local Coverage Determination (LCD) L36419 referenced by the Plan is retired and was not used in the 
our determination.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a group 1 standard power operated vehicle. You say that the item is 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a power mobility device or a push-rim activated 
power assist device is covered if specific criteria is 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 a group 1 standard power operated 
vehicle. Our reviewer says that the item is not medically necessary. Our physician reviewer found the 
documentation does reveal that you have a personal mobility deficit but it is not clear that this deficit impairs 
participation in mobility-related activities of daily living (MRADLs) in the home. The documentation does not 
clearly reveal why your mobility deficit is unable to be helped by a walker or manual wheelchair. The 
documentation is not clear that you can safely maneuver the power operated device on surfaces or around any 
obstacles in the home. There was no trial of the power operated scooter in the documentation. 
 
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 group 1 standard power operated vehicle have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (K0800).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Nivolumab (Opdivo) 
 
You asked the Plan to pre-approve Opdivo. The Plan denied your request. The Plan says that the enrollee has 
not been treated previously with Sorafenib. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Opdivo. Our physician reviewer found 
that the requested use of Opdivo is not FDA-approve for the treatment of hepatocellular carcinoma (either as a 
single agent or in combination with ipilimumab) in patients who have been previously treated with Sorafenib. 
However, the use is supported by one of the major drug compendia or by clinical research that appears in a 
CMS-approved medical journal. Especially because this enrollee is a poor candidate for Lenvatinib, Sorafenib, 
or Ateolizumab/bevacizumab as first line due to their increased risk of bleeding with recurrent severe GI 
bleeds. The documentation supports that the requested drug is safe and effective and otherwise reasonable and 
necessary for this enrollee. Opdivo is safer to use as first line over the other standard first line options. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have been met. Therefore, we decided that the Plan has to pre-approve 
Nivolumab (Opdivo)  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for tissue transfer (14301) provided on March 2, 2020. 
 
You asked the Plan to pay for tissue transfer. You say that this was medically necessary. The Plan denied your 
request. The Plan says this code is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 14301 is adjacent tissue transfer or rearrangement, any 
area; defect 30.1 sq cm to 60.0 sq cm. 
 
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 tissue transfer. Our reviewer says that this 
code is not supported by the records. Our physician reviewer found the operative report does not support that a 
adjacent tissue transfer or rearrangement was performed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of tissue transfer have not been met. Therefore, we decided that the Plan does not 
have to pay for tissue transfer (14301) provided on March 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental bridge. 
 
You asked the Plan to pre-approve a dental bridge. You say that the services are necessary. The Plan denied 
your request. The Plan says the services are 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 Plans 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 
dental bridge.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tumor treatment field therapy (TTFT). 
 
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 TTFT is covered for specific indications only. 
 
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 enrollee has a diagnosis of 
mesothelioma of the pleura. This is not a condition for which Medicare covers TTFT. The services are 
therefore 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 tumor treatment field therapy (TTFT).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator (63650). 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that the item is necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that dorsal column stimulators are covered under certain 
circumstances. 
 
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 spinal cord stimulator. Our reviewer 
says that the item is not medically necessary. Our physician reviewer found you do not have an evidence based 
indication for a spinal cord stimulation (SCS) trial. The procedure is not indicated here and is 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 a spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator (63650).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. 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. 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 medically necessary. Our physician reviewer found the enrollee is living at home and 
reports back pain and trouble walking. Her medical problems are stable. There are no identified problems that 
need inpatient medical management. There are no complex nursing or rehabilitation needs. The enrollee does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. The medical record supports a need for physical and occupational 
therapy but it does not support a need for an intensive rehabilitation therapy program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
July 6, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical 
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the 
type and quantity of items ordered and for the frequency of use.  
 
The record shows that documentation submitted did not indicate the provider discussed the need for the billed 
supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to 
pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on July 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block (77002, 64450). 
 
You asked the Plan to pre-approve the genicular nerve block. You say that you are requesting an appeal to 
reconsider this decision. It is your medical professional opinion that the enrollee would benefit from a genicular 
nerve block. The Plan denied your request. The Plan says this procedure is experimental and investigational as 
there is insufficient evidence to assess the safety and impact on health outcomes or patient management of 
genicular nerve blocks for knee pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the genicular nerve block have not been met. Therefore, we decided that the Plan does not have to 
pre-approve genicular nerve block (77002, 64450).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided on May 27, 2020. 
 
You asked the Plan to pay for the diabetic supplies. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the 
Proof of Delivery did not include details to corroborate the Delivery Ticket. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket 
does not have the tracking number on it and the Proof of Delivery does not have a description of the items 
delivered. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided on May 27, 
2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on July 11, 2018.

You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because the enrollee does not meet the criteria that reflect the standards of care for coverage of this testing.

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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered.

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 did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for genetic testing provided on July 11, 2018. &#8195;
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a transthoracic echocardiogram (TTE) with Doppler. 
 
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 that the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has multi-vessel coronary 
artery disease and previous myocardial infarction with stent placement. He recently had dizziness with elevated 
blood pressure. The TTE with Doppler is the standard of care and is reasonable and medically necessary at this 
time. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve a transthoracic echocardiogram (TTE) with Doppler.  
 
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.