Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous process 
stabilization/distraction device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the device remains experimental. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion of an interlaminar/interspinous process stabilization/distraction device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom foot orthotics. 
 
You asked the Plan to pre-approve these services. You say that your left leg is shorter than your right and you 
need these so that you don't limp while walking. The Plan denied your request. The Plan says the services are 
not covered. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve custom foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat (E0244). 
 
You asked the Plan to pre-approve a raised toilet seat. You say that the toilet seat is medically necessary. The 
Plan denied your request. The Plan says this is not a covered item. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat (E0244).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided May 16, 2020 to 
May 17, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services rendered are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee presented to the emergency department reporting fevers, fatigue, and 
chest pain for two weeks. Emergency care included laboratory studies, radiologic tests, electrocardiogram and 
intravenous fluids. The enrollee was diagnosed with a left lung pneumonia and small pleural effusion. Care 
plan included intravenous antibiotics, pulmonary consultation, repeat laboratory studies and isolation care 
pending COVID-19 testing.  Care provided to the enrollee was observation level. There were no advance 
interventions or complex medical conditions. The enrollee had stable vital signs and no complaints at the time 
of admission. Therefore, the enrollee did not meet criteria for the requested inpatient 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided May 16, 2020 to May 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic eye exam (92004) performed 
on July 27, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic eye exam. You say that this was a regular eye 
exam which was supposed to be free. The Plan denied your request. The Plan says the correct copayment was 
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 $50 
copayment for each Medicare-covered exam to diagnose and treat diseases or conditions of the eye.  
 
You have been asked to pay a $50 copayment for a diagnostic eye exam. The case record documents that the 
eye exam resulted in medical findings. It is therefore a diagnostic eye exam, which is distinct from a routine 
annual screening. A diagnostic eye exam falls within the "Vision care" 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 a diagnostic eye exam (92004) performed on July 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexcom G5/G4 sensors. 
 
You asked the Plan to pre-approve Dexcom G5/G4 sensors. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
item. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not do self-
adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided 
that Medicare rules for coverage of Dexcom G5/G4 sensors have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Dexcom G5/G4 sensors.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro Motion G Orthotic device. 
 
You asked the Plan to pre-approve MyoPro Motion G Orthotic device. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested item is 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 MyoPro Motion G Orthotic device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee had a stroke in February 2017 resulting in right dominant sided 
hemiparesis. Despite traditional therapies including modalities of e-stim and Botox, the enrollee continues to 
remain with a weak right upper extremity. The literature is insufficient in terms of effectiveness and safety of 
this device for the enrollee's condition of hemiparesis after stroke. At this time the requested orthosis is not 
proven to be more beneficial for treatment of the enrollee's medical condition of post stroke hemiparesis than 
any available standard of care therapy. Therefore, the enrollee does not meet criteria for the requested item. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro Motion G Orthotic device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve MyoPro Motion G Orthotic device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the company you used to get the 
supplies from is no longer in business. The Plan denied your request. The Plan says the services are not 
covered. 
 
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.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan 
denied your request. The Plan says the benefit has been exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on May 12, 2020, to May 18, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that this copayment is too 
high. 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 $390 
copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay a $390 copayment per day for days 1-5 for an inpatient hospital stay. The total 
amount you are being asked to pay is $1,950 ($390 x 5 days = $1,950). An inpatient hospital stay falls within 
the inpatient hospital care 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 an inpatient 
hospital stay provided by a participating provider on May 12, 2020, to May 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental extraction for tooth #19 provided on May 12, 
2020. 
 
You asked the Plan to pay for the extraction. You say that the tooth root became infected. 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 Plan?s coverage rules apply in this case. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the extraction services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
extraction for tooth #19 provided on May 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda/Pembrolizumab for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records did not contain enough details, such as office visit notes, test results, and 
treatment plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the submitted 
documentation includes PDL-1 test results but does not include any results for EGFR, ALK or other mutations. 
The use of Keytruda with Carboplatin and Pemetrexed is FDA indicated and compendium supported if there is 
no EGFR or ALK mutation. The NCCN Guidelines Version 2.2021 Non-small Cell Lung Cancer page NSCL-
18 through NSCL-31 outlines the use of molecular diagnostics to determine recommended first line treatment. 
Although NSCL-31 appears to support the use of the requested combination, that is only if there are no 
actionable molecular markers (page NSCL-19). The submitted documentation does not support that the 
requested drug combination is medically reasonable and necessary. The submitted documentation does not 
support that the drug combination is safe and effective 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda/Pembrolizumab for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve external bleaching for home application. 
 
You asked the Plan to pre-approve external bleaching. You say that half of your tooth broke and it is painful 
when brushing your teeth. The Plan denied your request. The Plan says the requested services are not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
external bleaching for home application.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
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 spinal stenosis. The 
requested spacer is considered experimental in nature, as more research is needed to show safety and efficacy. 
The services are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion spacer.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81455) provided on May 28, 2020. 
 
You asked the Plan to pay for genetic testing. You say that this code is supported. The Plan denied your request. The Plan 
says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a CGP service, test providers should use CPT 
code 81479. 
 
We looked at the file and Medicare rules. The record shows the service at issue was a CGP service. This should be 
reported with CPT 81479 rather than 81455. Based on this information, we decided that Medicare rules for coverage of 
genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81455) 
provided on May 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lift gate service (K0108). 
 
You asked the Plan to pre-approve lift gate service. You say that this is necessary. The Plan denied your 
request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for delivery of DME whether rented or 
purchased is generally included in the fee schedule allowance for the item. 
 
We looked at the file and Medicare rules. The requested service is not separately payable. Based on this 
information, we decided that Medicare rules for coverage of lift gate service have not been met. Therefore, we 
decided that the Plan does not have to pre-approve lift gate service (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the brief emotional/behavioral assessment services coded 
96127 and the rest home visit services coded 99336 provided on July 29, 2020. 
 
You asked the Plan to pay for the brief emotional/behavioral assessment services and the rest home visit 
services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The 
Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 96127 and 99336 are not supported in the medical record. Specifically, these services 
were billed with the GT modifier. This modifier is not to be billed for services provided not in a telehealth 
setting. The documentation does not support that these services were provided in the telehealth setting. Based 
on this information, we decided that Medicare rules for coverage of the brief emotional/behavioral assessment 
services and the rest home visit services have not been met. Therefore, we decided that the Plan does not have 
to pay for the brief emotional/behavioral assessment services coded 96127 and the rest home visit services 
coded 99336 provided on July 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4342), 
immediate maxillary denture (D5130), and removal of residual tooth rots (D7250). 
 
You asked the Plan to pre-approve the periodontal scaling and root planing,immediate maxillary denture, and 
removal of residual tooth rots. You say that the services are medically necessary for the enrollee. The Plan 
denied your request. The Plan says the services are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
periodontal scaling and root planing (D4342), immediate maxillary denture (D5130), and removal of residual 
tooth rots (D7250).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prolonged evaluation and management services (99354, 
99355) provided from July 10, 2020, to August 14, 2020. 
 
You asked the Plan to pay for prolonged evaluation and management services. You say that these services were 
required. The Plan denied your request. The Plan says these codes are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99354 is prolonged evaluation and management or 
psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other 
outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in 
addition to code for office or other outpatient Evaluation and Management or psychotherapy service), and 
99355 is prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of 
the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual 
service; each additional 30 minutes (List separately in addition to code for prolonged service). 
 
We find that CPT code 99354 and 99355 is not supported in the medical record. Specifically, the submitted 
medical records do not document that the observation services required direct patient contact. Based on this 
information, we decided that Medicare rules for coverage of prolonged evaluation and management services 
 
 
have not been met. Therefore, we decided that the Plan does not have to pay for prolonged evaluation and 
management services (99354, 99355) provided from July 10, 2020, to August 14, 2020.