Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the consultation (99205) and office visits (99215) with 
a Gastroenterology specialist. 
 
You asked the Plan to pre-approve the consultation and office visits. You say that you have been going to this 
provider for the past 10 years and you would like to stay with this provider. The Plan denied your request. The 
Plan says the records do not show the medical necessity for this level of specialty care. The plan has instead 
approved for consultation and office visit with a community specialist in gastroenterology. 
 
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 the consultation and office visit. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a history of polyps that require re-surveillance, evaluation 
and procedural performance of which the community specialist is appropriately qualified. The available records 
do not support that the enrollee is at too high a risk or is not safe to perform his consultation and follow-up 
colonoscopy at a non-tertiary level of care. The plan's referred community specialist is the founder and 
president of these consultants, with practice locations convenient to 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 the consultation and office visit have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the consultation (99205) and office visits (99215) with a
Gastroenterology specialist.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of excessive skin and tissue (15830, 15834, 
15836, 15837) to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the removal of excessive skin and tissue. You say that you have gone to all 
the doctors in and out of network. The Plan denied your request. The Plan says care can be provided for you by 
a doctor in your network. 
 
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 removal of excessive skin and tissue (15830, 15834, 15836, 15837) to be provided by an out of network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orange piping accents, a privacy flap, and a transport 
system (K0108) for a wheelchair. 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that the items should be covered. The 
Plan denied your request. The Plan says the piping accents and privacy flap do not serve a primarily medical 
purpose and are non-covered. The transport accessory is for use outside the home and is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. Rules also say that DME for use outside the home is not covered. 
 
The orange piping accents and privacy flap do not serve a purpose that is primarily medical in nature. The 
transport accessory is to allow use of the DME item outside the home. These items are non-covered. Therefore, 
we decided that the Plan does not have to pre-approve orange piping accents, a privacy flap, and a transport 
system (K0108) for a wheelchair.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve the OmniSeq Advance Panel for the enrollee. 
 
You asked the Plan to pre-approve the panel. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered 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 panel. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the use of next generation sequencing (NGS) or molecular profiling is recommended by the NCCN 
Guidelines for patients with endometrial cancer.  Molecular analysis (eg, identification of characteristic 
translocations) can help classify difficult cases and provide future therapeutic targets. This enrollee. has a 
difficult case and meets this criteria. The service is reasonable and 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 panel have been met. Therefore, we decided that the Plan has to pre-approve 
the OmniSeq Advance Panel 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture. 
 
You asked the Plan to pre-approve the complete mandibular denture. You say that this denture is medically 
necessary for you to receive. The Plan denied your request. The Plan says this service is allowed one time 
every 60 months. The Plan also says that you had this service less than 60 months ago. 
 
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, dentures are limited to 1 complete or 
partial denture every 5 years. The record shows that you received a mandibular partial denture on March 5, 
2019, and your mandibular denture benefit has been exhausted. Therefore, we decided that the Plan does not 
have to pre-approve a complete mandibular denture.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ExoDx Prostate IntelliScore (EPI) testing. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records received did not contain certain details needed to process the request. 
 
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 the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case your prostate blood test was abnormal last year. You had a biopsy of his prostate 
performed which demonstrated cancer. Your prostate test remains elevated. Your provider recommends the EPI 
test. This request cannot be approved because Medicare rules state this test should be performed prior to the 
initial biopsy. The review has determined that the requested molecular and genomic testing is not medically 
reasonable and 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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ExoDx Prostate IntelliScore (EPI) testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued rental of a continuous positive airway 
pressure (CPAP) device and humidifier. 
 
You asked the Plan to pre-approve continued rental of a continuous positive airway pressure (CPAP) device 
and humidifier. You say that continued rental of a continuous positive airway pressure (CPAP) device and 
humidifier is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are 
not met. 
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this device. 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 continued rental of a continuous positive airway 
pressure (CPAP) device and humidifier. Our reviewer says that Medicare coverage criteria are not met. Our 
physician reviewer found the medical records do not show documentation of a clinical re-evaluation by the 
treating practitioner since the ordering of CPAP and supplies. There is no documentation of adherence to 
therapy and documentation of clinical benefit from CPAP. The documentation does not support that the 
coverage criteria for continuation of CPAP have been met 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 
continued rental of a continuous positive airway pressure (CPAP) device and humidifier have not been met. 
Therefore, we decided that the Plan does not have to pre-approve continued rental of a continuous positive 
airway pressure (CPAP) device and humidifier.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-medically necessary service (S9986) to be covered 
under the special supplemental benefits for chronically ill. 
 
You asked the Plan to pre-approve the non-medically necessary service. You say that you were told by the 
representative that you would have supplementary benefits as soon as you entered the plan. You were not told 
that you needed to meet certain criteria to become eligible for benefits. The Plan denied your request. The Plan 
says the enrollee does not meet the criteria for the special supplemental benefits for chronically ill. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the non-medically necessary service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve non-medically necessary service (S9986) to be covered under the special supplemental 
benefits for chronically ill.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Special Supplemental Benefits for the Chronically Ill 
(S9986). 
 
You asked the Plan to pre-approve the special supplemental benefits. You say that the benefits should be 
available for all enrollees. The Plan denied your request. The Plan says you are not eligible for the special 
benefits because you do not have a qualifying diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. These services are not covered 
by Medicare. In this case, the plan's rules apply. 
 
We looked at the file and the health plan's rules. The record shows you do not have a qualifying diagnosis 
which makes you eligible for the special supplemental benefits. Based on this information, we decided that 
Medicare rules for coverage of the special supplemental benefits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Special Supplemental Benefits for the Chronically Ill (S9986).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental item. You say that you cannot chew correctly without teeth. You 
say that when you received your dentures, they started to fall out. You also say that the dentist made multiple 
attempts to repair them but nothing worked. The Plan denied your request. The Plan says dentures are covered 
once every 5 plan years. The Plan says the frequency limit has been reached. 
 
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 and an upper denture is a covered 
service, the frequency limit of once every 5 plan years has been reached. The record shows that the Plan paid 
for a complete upper denture that you received on October 15, 2020. Therefore, we decided that the Plan does 
not have to pre-approve a complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gym membership (S9970). 
 
You asked the Plan to pre-approve the gym membership. You say that this gym membership is medically 
necessary. The Plan denied your request. The Plan says fitness benefits are covered only when received from 
an in-network facility. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits 
only when received through an in-network gym. 
 
The Plan's rules for coverage of gym benefits have not been met because the requested fitness program is not 
provided by an in-network provider. Therefore, we decided that the Plan does not have to pre-approve a gym 
membership (S9970).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveseat elevator (CPT Code E2300).You asked the Plan to pre-approvethe seat elevator. You say that the seat elevator is necessary.The Plandenied your request. The Plan says the Seat Elevator does not serve a primary medical purpose and is statutorily non-covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The Seat Elevator is requested to improve ability to perform transfers and activities of daily living (ADLs). The Seat Elevator does not serve a primary medical purpose and is statutorily non-covered. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approveseat elevator (CPT Code E2300).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approvean Exogen Ultrasound bone healing system.You asked the Plan to pre-approvethe system. You say that this is medicallynecessary.The Plan denied your request. The Plan says that there is no evidence of non-union of a long bone fracture.The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. 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 system is medically reasonable and necessary. Our physician reviewer found you went underwent revision right wrist total arthrodesis with bone morphogenetic protein/bone graft on 6/19/20. You present with continued pain and swelling of the right wrist. X-rays on 7/28/20 reportedly showed you were status post total wrist arthrodesis with a dorsal bridge plate with no signs of hardware loosening. The physician said he thought he saw some signs of fusion mass progressing. Under consideration is a request for a bone growth stimulator. Medicare criteria (and/or intent) have been essentially met. You were status post multiple surgical procedures including a prior failed fusion. There is also likely age-related osteopenia. These factors evidence a significant increased risk of non-union with associated morbidity. There is support therequest for a bone growth stimulatoras an indicated relative guideline exception.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 been met.Therefore, we decided that the Plan has to pre-approvean Exogen Ultrasound bone healing system.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies (T4521). 
 
You asked the Plan to pre-approve incontinence supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies (T4521).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the neurology services (99204, 99214) to be provided 
by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the neurology services. You say that you were experiencing difficult 
problems with the Sinemet medication and needed advice immediately. The Plan denied your request. The Plan 
says they are able to safely provide the requested service in network. 
 
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 neurology services (99204, 99214) to be provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve additional physical therapy visits. You say that physical therapy is 
medically necessary. The Plan denied your request. The Plan says additional visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional physical therapy visits.. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the enrollee has had extensive therapy for this 
condition and has been educated in a home exercise program. Our reviewer says that the unique skills of a 
professional therapist are not required to safely and effectively provide ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional physical therapy visits. have not been met. Therefore, we decided 
that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the power wheelchair. You say that you would like to file for a GAP 
Exception. The Plan denied your request. The Plan says the service requested is available in-network. 
 
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 power wheelchair to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous glucose monitor for the enrollee.You asked the Plan to pre-approvethe monitor. You say that this is medically necessary.The Plan denied your request. The Plan says the criteria for a continuous glucose monitor requires three or more daily insulin injections or a continuous insulin pump and checking blood sugar four or more times a day. 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 carefullyreview the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is diabetic, but not on insulin. The enrollee does not have an insulin pump.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 monitor have not been met.Therefore, we decided that the Plan does not have to pre-approvea continuous glucose monitor for the enrollee.