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

 
We decided that the Plan does not have to pay for a duplex scan provided on January 14, 2020. 
 
You asked the Plan to pay for the duplex scan. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
duplex scan. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a duplex scan provided on January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-ray (D0220), the bitewing x-ray (D0274), 
and the palliative (emergency) treatment (D9110) provided on June 3, 2020. 
 
You asked the Plan to pay for the dental services. You say that this visit was an emergency visit for a cracked 
tooth not pain relief. The Plan denied your request. The Plan says the periapical x-ray is not listed as a covered 
service. The Plan says bitewing x-rays are not listed as a covered service. The Plan says palliative treatment is 
not listed as a covered service either. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 pay for the 
periapical x-ray (D0220), the bitewing x-ray (D0274), and the palliative (emergency) treatment (D9110) 
provided on June 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider. 
 
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 available from network providers. 
 
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. The Plan confirmed that the providers are 
able to provide the requested services to the enrollee. 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 a referral to 
an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 19, 2019 by a 
non-participating provider. 
 
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 rendered by a non-participating provider without prior authorization. 
 
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 referring provider 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 laboratory services provided on December 19, 2019 by a non-participating provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0998) provided January 3, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the service should be paid because you did 
not call for the ambulance. 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 January 3, 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 ambulance services (A0998) provided January 3, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper eyelid blepharoplasty surgery. 
 
You asked the Plan to pre-approve blepharoplasty. You say that your vision is being impaired because of the 
extra skin on your eyelid. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because documentation does not show that a functional deficit exists that interferes with 
activities of daily living and visual testing did not indicate approximately visually-significant field restriction of 
30 degrees or less from fixation. 
 
The Plan follows Medicare rules. Medicare rules say that blepharoplasty is only covered under certain clinical 
conditions. 
 
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 blepharoplasty. Our reviewer says that 
you do not meet the Medicare criteria for the requested upper eyelid blepharoplasty. Our physician reviewer 
found the documentation does not support that you have redundant eyelid tissue hanging over the eyelid margin 
resulting in pseudoptosis where the "pseudo" margin produces a central Margin Reflex Distance of 2.0mm or 
less. The documentation does not support that you have redundant eyelid tissue - predominantly medially or 
laterally - that clearly obscures the line of sight in corresponding gaze. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of blepharoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve upper eyelid blepharoplasty surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveFreestyle Libre 14 Day Sensor.You asked the Plan to pre-approvethe sensor. You say that the sensor is necessary.ThePlan denied your request. The Plan says the Medicare rules have not been 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 the sensor. Our physician reviewer found the criteria call for continuous glucose monitors (CGM) use in patients who takes multiple insulin shots and monitor blood glucose multiple times. We are not told in the office notes that you have diabetes mellitus, nor why you need to check blood glucose, nor that you are taking insulin. The criteria are not met.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 sensor have not been met.Therefore, we decided that the Plan does not have to pre-approveFreestyle Libre 14 Day Sensor.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the extraction of an erupted tooth or exposed root (D7140) for 
tooth # 2. 
 
You asked the Plan to pre-approve the dental service. You say that you have included additional information to 
help resolve the problem about the extraction of tooth # 2. The Plan denied your request. The Plan says that 
tooth # 2 has been extracted previously. 
 
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 dental 
service when the services are medically necessary and reasonable. 
 
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 dental service. Our reviewer says 
that the service meets the criteria for coverage. Our physician reviewer found the provided documentation 
indicates the presence of a portion of a root segment from tooth # 2. The reviewer found that it is reasonable 
that this retained segment be removed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service have been met. Therefore, we decided that the Plan has to 
pre-approve the extraction of an erupted tooth or exposed root (D7140) for tooth # 2.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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 must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan (71260) provided on 
March 13, 2020. 
 
You asked the Plan to pay for a CT scan. You say that this should be covered. The Plan denied your request. 
The Plan says this was not billed with an appropriate primary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that the ICD-10-CM has a coding convention that 
requires the underlying condition be sequenced first, if applicable, followed by the manifestation. 
 
We looked at the file and Medicare rules. The service at issue was billed with diagnosis code J68.0 as the first 
and primary diagnosis; however, this code is a manifestation code and should be billed after the etiology code. 
Based on this information, we decided that Medicare rules for coverage of a CT scan have not been met. 
Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan (71260) 
provided on March 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upper partial denture. 
 
You asked the Plan to pre-approve the upper partial denture. You say that the old partial does not fit. The 
enrollee needs a new partial to restore oral health. The Plan denied your request. The Plan says this service is 
only allowed one time in 5 calendar years. 
 
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 Plan also has a maximum benefit 
of one set of complete or partial denture every five years. The Plan paid for partials dentures provided on June 
28, 2018, which exhausted the benefit. Therefore, we decided that the Plan does not have to pre-approve the 
upper partial denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve the HFCWOD. You say that although the enrollee does not have cystic 
fibrosis or bronchiectasis, there is a need for airway clearance. The Plan denied your request. The Plan says the 
records show you have COPD but you do not have a confirming diagnosis of bronchiectasis. Therefore, you do 
not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 
The record does not show that you have cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. 
This means that you do not have a medical condition for which a high frequency chest wall oscillation devise 
can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve high 
frequency chest wall oscillation device (HFCWOD).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 10, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.   
 
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 did not pre-approve the 
laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on February 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this enrollee requires and will benefit from intensive 
rehabilitation, and is expected to be able to tolerate an intensive program. The Plan denied your request. The 
Plan says acute inpatient rehab is not medically necessary for this enrollee. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the documentation does not support that there is a need for an intensive therapy 
program with 3 hours a day and an interdisciplinary approach to rehab care. Our reviewer found that the 
enrollee does not meet the coverage criteria for an IRF admission due to lack medical complexity and high 
functional level. Our physician reviewer also found that the enrollee's rehab needs can be met in an alternate, 
less intense setting such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601). 
 
You asked the Plan to pre-approve a CPAP device. You say that this should be covered. The Plan denied your 
request. The Plan says the documentation does not show that the criteria for coverage have been met. 
 
The Plan must follow Medicare rules. Medicare rules say that continued coverage of a PAP device requires an 
in-person clinical re-evaluation by the treating practitioner with documentation that symptoms of obstructive 
sleep apnea are improved. 
 
 
 
 
 
We looked at the file and Medicare rules. The submitted medical records do not include documentation of an 
in-person clinical re-evaluation by the treating practitioner with documentation that symptoms of obstructive 
sleep apnea are improved. Based on this information, we decided that Medicare rules for coverage of a CPAP 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
positive airway pressure (CPAP) device (E0601).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider on 
February 15, 2019. 
 
You asked the Plan to pay for physical therapy. You say that you are appealing unpaid bills for services 
recommended by your primary care physician. The Plan denied your request. The Plan says the service requires 
prior authorization and there is insufficient information to determine medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must submit sufficient information 
to confirm that coverage criteria have been met and to determine whether payment is due.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pay for 
physical therapy provided by an out-of-network provider on February 15, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee arthroscopy. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee presented on August 12, 
2020 with complaints of severe right knee pain. Pain increased with weight bearing and at night. Clinical exam 
findings documented mild effusion, limited flexion and medial joint line tenderness. There is no clear 
documentation that this enrollee presents with mechanical symptoms to support proceeding with surgery. There 
is no clear documentation of meniscal provocative testing to support surgery as safe and effective. Additionally, there is no clear discussion of a trial of reasonable and/or comprehensive treatment as surgery was requested within one month of apparent initiation of treatment. Therefore, the requested knee arthroscopy would not be considered the standard of care and medically reasonable and 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 a knee arthroscopy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the extraction. You say that you are in pain, and need to have these 
extractions done. You also say that you contacted all of the dentists that were provided to you, but none of 
them do extractions. The Plan denied your request. The Plan says services performed by an oral surgeon 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 
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve an extraction to be provided by an oral surgeon.
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 the enrollee is making 
improvements in her pain level and function. You say that denial of services would limit her capacity for 
improvement. 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 was educated in an independent 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.