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

 
We decided that the Plan does not have to pre-approve a StimQ Stimulator. 
 
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 peripheral nerve stimulation 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 enrollee has chronic shoulder pain. 
He has had past shoulder surgery, but the history and physical exam does not delineate the nature of the prior 
surgery or current range of motion/ associated joint findings. A peripheral nerve stimulator should be used as a 
late/last resort. The enrollee has not had a recent surgical evaluation or trials of other conservative therapies. 
The request is not medically reasonable or necessary at this point. 
 
 
 
 
 
 
 
 
 
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 StimQ Stimulator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance spectroscopy (MRS) (76390). 
 
You asked the Plan to pre-approve magnetic resonance spectroscopy. You say that this is necessary to analyze 
the brain and its volume in specific areas. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS considered MRS an investigational 
procedure and issued a national noncoverage determination for all indications of MRS.  
 
We looked at the file and Medicare rules. The requested service is not covered. Based on this information, we 
decided that Medicare rules for coverage of magnetic resonance spectroscopy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve magnetic resonance spectroscopy (MRS) (76390).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for telemedicine services provided by a 
participating provider on April 27, 2020. 
 
You asked the Plan to waive the copayment for telemedicine services. You say that you were only on the phone 
for 2 minutes. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $45 
copayment for physician/practitioner services.  
 
You have been asked to pay a $45 copayment for specialist telemedicine services. Since telemedicine services 
were provided, the correct copayment has been applied. Telemedicine services fall within the 
physician/practitioner services 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 copayment for 
telemedicine services provided by a participating provider on April 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on August 19, 2020. 
 
You asked the Plan to waive the copayment for the eye exam. You say that the office visit was for a post-
operative exam of the eyes. You say that you don't think you should be charged. The Plan denied your request. 
The Plan says the copayment applied 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 $35 
copayment for Medicare covered vision services at an in-network specialist's office. 
 
You have been asked to pay a $35 copayment for the eye exam. The eye exam falls within the "Vision care" 
benefit category. The Plan says that you were not charged for visits during the 90 day post-operative period. 
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 eye exam provided on August 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drugs or medicaments. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
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 
drugs or medicaments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device with sleeves provided on 
August 20, 2020. 
 
 
You asked the Plan to pay for pneumatic compression device. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of payment for these items is correct, because 
these items do not meet the Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device is only covered 
if a 6-month trial of conservative therapy has been attempted, demonstrating failed response.  
 
We looked at the file and Medicare rules. The records submitted do not show that a 6-month trial meeting all of 
the required criteria was performed and failed prior to the provision of these items. Based on this information, 
we decided that Medicare rules for coverage of pneumatic compression device have not been met. Therefore, 
we decided that the Plan does not have to pay for a pneumatic compression device with sleeves provided on 
August 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for screening digital breast tomosynthesis (77062) provided July 
23, 2020. 
 
You asked the Plan to pay for the breast tomosynthesis. You say that medical records are attached to support 
the services rendered. Please review and reconsider the claim for payment. The Plan denied your request. The 
Plan says invalid procedure code for this service 
 
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 77062 is screening digital breast tomosynthesis, bilateral 
(list separately in addition to code for primary procedure). 
 
We find that CPT code 77062 is not supported in the medical record. Specifically, 77062 has a status code of 
"I". Medicare guidance says status code "I" is not valid for Medicare purposes. Medicare uses another code for 
reporting of and payment for these services. Based on this information, we decided that Medicare rules for 
coverage of the breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to 
pay for screening digital breast tomosynthesis (77062) provided July 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided there is 
no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment 
of a skilled professional nurse is not required to safely and effectively provide medically necessary and 
reasonable treatment. Based on the medical records provided you do not require skilled therapy services, i.e., 
the specialized skill, knowledge and judgment of a qualified therapist is not required to safely and effectively 
provide medically necessary and reasonable treatment. Daily skilled services are not required. You do not 
require the services on an inpatient basis, in a skilled nursing facility setting. Services in a long-term care 
facility on a part time basis or in the home with home health services appear appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services for bathing, 3 times a week 
for 3 months. 
 
You asked the Plan to pre-approve home health aide services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 home health aide services. Our 
reviewer says that the documentation does not support that the requested home health aide services are 
medically reasonable or necessary. Our physician reviewer found you recently had a fall at home and were 
diagnosed with contusion of the right knee during his visit at the Emergency Department. You were ordered 
and provided an elastic knee brace. The documentation does not support that you require skilled therapy or 
skilled nursing services. Therefore, you do not meet criteria for the requested home health 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 home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health aide services for bathing, 3 times a week for 3 months.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport provided to the enrollee on February 9, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim must be submitted to Original Medicare first before it can be reviewed by the 
Plan. Original Medicare must issue an Explanation of Benefits showing they completed their review. 
 
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 on February 
12, 2020. The services in question were provided before the end of that month. Therefore, we decided that the 
Plan does not have to pay for ambulance transport provided to the enrollee on February 9, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One (J7326). 
 
You asked the Plan to pre-approve Gel-One. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gel-One. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the health plan requires that other forms 
of hyaluronic acid injections be used. There is no evidence that you are allergic to or intolerant of these other 
forms of hyaluronic acid. There is no evidence that you have tried and not responded to these other forms of 
hyaluronic acid injections. There is no documentation as to why these other forms of hyaluronic acid would not 
be expected to be safe and effective for you. Therefore, the requested Gel-One is not shown to be currently 
 
 
medically necessary and reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One (J7326).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids. 
 
You asked the Plan to pre-approve hearing aids. You say that the item is medically necessary. The Plan denied 
your request. The Plan says you have exhausted your maximum benefits for this item. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan pays for one 
hearing aid per ear every three years.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Specifically, records show you received a new pair of hearing aids 
in March 2018 and are not available for another new pair until March 2021. Therefore, we decided that the Plan 
does not have to pre-approve hearing aids.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging (78452). 
 
You asked the Plan to pre-approve myocardial perfusion imaging. You say that the services are 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 cardiovascular nuclear imaging is 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 myocardial perfusion imaging. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the records 
the enrollee has known coronary disease (focal regional LV dysfunction) but no symptoms and no revocable 
ischemia on suboptimal stress testing less than 2 years ago. In this circumstance of a clinically stable enrollee 
with no symptoms the records do not support the medical necessity for repeat stress testing at this time. 
Aggressive risk factor modification in indicated regardless of stress test results. Coverage criteria for stress 
testing are not met since there are no documented covered indications for the procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve myocardial perfusion imaging (78452).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lightweight wheelchair. 
 
You asked the Plan to pre-approve the lightweight wheelchair. You say that you would like reconsideration 
because the wheelchair will help your caregiver transport you into the vehicle when you have to go to 
appointments. The Plan denied your request. The Plan says a manual wheelchair to be used outside the home is 
not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve the lightweight wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intermittent urinary catheters (A4352) to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve intermittent urinary catheters. You say that the items are necessary. The 
Plan denied your request. The Plan says the items can be provided by an in-network supplier. Therefore, 
coverage criteria has 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. 
 
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 
intermittent urinary catheters (A4352) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT) for non-small 
cell lung cancer (NSCLC). 
 
You asked the Plan to pre-approve the requested PBRT. You say that PBRT is requested in order to best 
localize the radiation doses to prevent negative side effects of treatment that would reduce its palliative effect. 
The Plan denied your request. The Plan says the provider documents the plan to use proton therapy is to spare 
the contralateral lung and reduce the risk of pneumonitis. There is no documentation provided as to why this 
cannot be achieved with 3D conformal or IMRT. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested PBRT. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found proton therapy is an accepted, safe and effective treatment modality for curative treatment of 
Stage II-III lung cancer, and the most recent (v8.2020) NCCN guidelines for NSCLC include proton therapy as 
a means to deliver conformal radiation, although do not address specific indications for proton therapy over 
intensity-modulated radiation therapy (IMRT). Thus, the need for proton therapy for advanced lung cancer 
needs to be established on an individual basis with a plausible rationale as to why proton therapy is needed in 
lieu of more standard 3D conformal radiation or IMRT. 
 
This patient is being offered palliative radiation, with a low dose of 30 Gy in 12 fractions. The case records 
provide no plausible benefit for proton therapy over IMRT of 3D conformal radiotherapy. DVH comparisons 
are provided though no DVH shows an unacceptable non-proton plan. Proton therapy will always reduce 
normal tissue exposure but not always in a clinically meaningful manner. In order to establish medical 
necessity, a plausible clinical benefit should be demonstrated. As such, this treatment is not deemed 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 requested PBRT have been met. Therefore, we decided that the Plan does 
not have to pre-approve proton beam radiation therapy (PBRT) for non-small cell lung cancer (NSCLC).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transforaminal lumbar interbody fusion (TLIF). 
 
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 the enrollee has a history of sciatica. 
There is no documented lumbar instability. The requested TLIF is therefore not reasonable or 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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve transforaminal lumbar interbody fusion (TLIF).