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

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with accessories. 
 
You asked the Plan to pre-approve group 3 power wheelchair. You say that you are appealing. The Plan denied 
your request. The Plan says the denial of authorization for this device is correct, because the enrollee does not 
meet the criteria for a group 3 power wheelchair and a group 2 power wheelchair may be appropriate instead.  
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The 
rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation 
that is due to a neurological condition, myopathy, or congenital skeletal deformity. 
 
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 group 3 power wheelchair. Our 
reviewer says that the enrollee does not meet the Medicare criteria for a group 3 power wheelchair. Our 
physician reviewer found the enrollee has an ataxic gait following a traumatic brain injury. The enrollee uses a 
wheelchair for activities of daily living and does limited walking with a cane. The documentation does not 
 
 
support that the requested group 3 power wheelchair is medically reasonable and necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of group 3 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 3 power wheelchair with accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildup (D2950) and pontic - porcelain used to 
fuse metal (D6240). 
 
You asked the Plan to pre-approve the core buildup and pontic - porcelain used to fuse metal. You say that the 
services you are requesting are medically necessary for your condition. The Plan denied your request. The Plan 
says these services are not covered under your 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 the 
core buildup (D2950) and pontic - porcelain used to fuse metal (D6240).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for debridement provided from June 5, 2020, 
to July 31, 2020. 
 
You asked the Plan to waive the copayments for debridement. You say that your copayment should not be this 
high because the facility does not have operating room facilities and is just a regular doctor's office. 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 a $285 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You received debridement at an outpatient hospital facility from June 5, 2020, to July 31, 2020, for a total of 6 
services. Debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay a 
$285 (copayment) x 6 (debridement services) = $1,710.  
 
You have been asked to pay the total copayment amount of $1,710 for debridement. Debridement falls within 
the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers 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 copayments for debridement provided from 
June 5, 2020, to July 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular genetic testing provided on June 23, 2020. 
 
You asked the Plan to pay for the molecular genetic testing. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 molecular genetic testing at issue in this appeal was 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 the molecular genetic testing provided on June 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite filling (D2391) and unspecified 
preventative procedure (D1999). 
 
You asked the Plan to pay for the resin-based composite filling and unspecified preventative procedure. You 
say that the services provided The Plan denied your request. The Plan says you have exhausted Plan benefit for 
the filling and the unspecified preventative procedure is not covered. 
 
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 resin-
based composite filling when the services are medically necessary and reasonable. 
 
We looked at the file and Medicare rules. It appears that you already have had two fillings covered by the Plan 
therefore exhausting the benefit limits. Based on this information, we decided that the Plan's rules for coverage 
of the resin-based composite filling have not been met. Furthermore, though the Plan offers a dental benefit in 
excess of Medicare coverage, the unspecified preventative procedure is not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pay for the resin-based composite filling (D2391) 
and unspecified preventative procedure (D1999).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on July 22, 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 22, 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 by you on July 
22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on September 12, 
2020. 
 
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services received are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor on September 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Necitumumab. 
 
You asked the Plan to pre-approve the Necitumumab. You say that the best outcomes can be achieved using the 
drug requested. You say that the denial is based on cost rather than data. You say that the addition of the drug 
in dispute is an FDA approved first line regimen and has been shown to improve patient survival in advanced 
lung cancer. You say that the enrollee has no options for checkpoint inhibitors. The Plan denied your request. 
The Plan says the addition of Necitumumab to the regimen is not beneficial based on toxicity, cost, and limited 
improvement in efficacy when compared with Cisplatin/Gemcitabine. 
 
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 the Necitumumab. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found Necitumumab is FDA approved 
for first-line treatment of metastatic squamous non-small cell lung cancer (NSCLC) in combination with 
gemcitabine and cisplatin. The study included patients who had not received prior chemotherapy. This patient 
is on 2nd line therapy and would not meet criteria. The service is 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 the Necitumumab have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Necitumumab.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 15, 2020, by an out-
of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says prior authorization was not obtained by the provider or facility. 
 
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 June 15, 2020, 
by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prefabricated post and core in addition to crown 
(D2954) and endodontic therapy (D3310). 
 
You asked the Plan to pre-approve the prefabricated post and core in addition to crown and endodontic therapy. 
You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says 
these are both not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
prefabricated post and core in addition to crown (D2954) and endodontic therapy (D3310).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on July 9, 2019. 
 
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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that HHAs must report an additional line item with the 
same revenue code and date of service, reporting one of the three Q codes (Q5001, Q5002, and Q5009), one 
unit and a nominal covered charge.  
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with one of the required 
Q codes. 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 home health services rendered on 
July 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital bed (E0255) provided from July 12, 2019, to 
December 12, 2019. 
 
You asked the Plan to pay for a hospital bed. You say that this was medically necessary. The Plan denied your 
request. The Plan says a physician order and proof of delivery have not been submitted. 
 
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 physician order and proof of delivery for the supplies provided in this case. 
These documents have not been submitted. 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 a 
hospital bed (E0255) provided from July 12, 2019, to December 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental implant services provided on February 27, 2020. 
 
You asked the Plan to pay for the dental services. You say that your brochure states that restorations are 
covered. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the service at issue is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
implant services provided on February 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the pulp vitality test 
(D0460) provided on July 30, 2020. 
 
You asked the Plan to pay for the dental services. You say that your regular dentist advised you needed a root 
canal. You say that you went to another dentist and they did the same thing your regular dentist did plus the 
root canal. You say that you did not know that the plan only covered this once. You also say that you cannot 
afford to pay for this. The Plan denied your request. The Plan says 1 emergency exam is provided in a 12-
month period. The Plan says that the frequency limit for this service has been exceeded. The Plan also says that 
pulp vitality test is not listed as a covered service. 
 
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 frequency limit of 1 emergency 
exam in a 12-month period has been exceeded. The record shows that the Plan paid for this service that you 
received on July 14, 2020, thus exhausting the benefit. Additionally, the pulp vitality test is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) and the pulp vitality test (D0460) provided on July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services rendered on August 26, 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 were not performed by a physician. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. The file shows that the services were not performed by a physician 
licensed to perform acupuncture. Based on this information, we decided that the Plan?s rules for coverage of 
the acupuncture services have not been met. Therefore, we decided that the Plan does not have to pay for the 
acupuncture services rendered on August 26, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve tenodesis of long tendon of biceps (23430), arthroscopy, shoulder, 
surgical; debridement, extensive (29823), and arthroscopy, shoulder, surgical, distal claviculectomy including 
distal articular surface (29824) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the enrollee has had at least 3 months of 
conservative treatment. The Plan denied your request. The Plan says that that given the member's clinical 
course and short duration of pain, it likely makes sense to avoid surgery and try conservative management. 
 
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 requested services are considered medically reasonable and necessary in this case. This enrollee presents 
with persistent left shoulder pain and weakness. Clinical exam findings have been consistent with rotator cuff 
tendinosis, loose body present in the rotator interval on the anterior aspect of the shoulder, degenerative tearing 
in the superior region of the glenoid, and AC joint degenerative changes. He has failed to improve with 
reasonable and/or comprehensive conservative treatment for over 3 months. Under consideration is a request 
for left shoulder arthroscopy, debridement with loose body removal, arthroscopic distal clavicle excision, and 
likely biceps tenodesis depending on the intra-operative findings concerning SLAP tear and the appearance of 
the biceps tendon. Current evidence based medical literature would support proceeding with surgery at this 
time for functional restoration. Our physician reviewer found that the enrollee's condition meets criteria for 
coverage of these services. 
 
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 tenodesis of long tendon of biceps (23430), arthroscopy, shoulder, surgical; debridement, extensive 
(29823), and arthroscopy, shoulder, surgical, distal claviculectomy including distal articular surface (29824) for 
the enrollee.  
 
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 19, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you did not order this service. 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 19, 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 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the twenty-one (21) office visits (99212),  therapeutic 
procedures (97116), electrical stimulation (G0283), application of a modality to one or more areas (97032), 
therapeutic, prophylactic or diagnostic injections (96372), injections, thiamine (J3411), injection, pyridoxine 
(J3415) and unclassified drugs (J3490) to be provided by an out of network (OON) provider.  
 
You asked the Plan to pre-approve 21 electrical cell stimulation treatments (using the Senexas device). You say 
that the service is medically necessary. The Plan denied your request. The Plan says you do not meet the 
exception to use an out of network provider, the requested service for 21 Electrical Cell Stimulation treatments 
(using the Sanexas device) is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the twenty-one (21) office visits (99212),  therapeutic procedures (97116), electrical stimulation (G0283), 
application of a modality to one or more areas (97032), therapeutic, prophylactic or diagnostic injections 
(96372), injections, thiamine (J3411), injection, pyridoxine (J3415) and unclassified drugs (J3490) to be 
provided by an out of network (OON) provider.