Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nucynta tablets. 
 
You asked the Plan to pre-approve Nucynta tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Nucynta tablets are not covered under the enrollee's 
Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nucynta tablets.  
 
Benefits for Nucynta tablets may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve jaw surgery and dental implants. 
 
You asked the Plan to pre-approve jaw surgery and dental implants. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested dental services are not 
covered by Medicare or the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that 
are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve jaw 
surgery and dental implants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ankle-foot orthosis (L1940) and additions (L2820 
and L2330). 
 
You asked the Plan to pre-approve an ankle-foot orthosis (L1940) and additions (L2820 and L2330). You say 
that the requested ankle-foot orthosis (L1940) and additions (L2820 and L2330) are medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the ankle-foot orthosis (L1940) 
and additions (L2820 and L2330) . 
 
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 an ankle-foot orthosis (L1940) and 
additions (L2820 and L2330). Our reviewer says that the enrollee does not meet criteria for the ankle-foot 
orthosis (L1940) and additions (L2820 and L2330). Our physician reviewer found the documentation does not 
support that the enrollee has a covered indication for the requested ankle-foot orthosis (L1940) on a physical 
examination. There is no evidence of ankle or foot instability on a physical exam. As the  basic coverage 
criteria for an AFO have not been met the requested additions (L2820 and L2330) are also 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 an ankle-foot orthosis (L1940) and additions (L2820 and L2330) have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an ankle-foot orthosis (L1940) and 
additions (L2820 and L2330).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home oxygen equipment (E1390, E0431, E0443). 
 
You asked the Plan to pre-approve the home oxygen equipment. You say that the home oxygen is medically 
necessary. The Plan denied your request. The Plan says based on the records provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or 
arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.   
 
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 home oxygen equipment. Our 
reviewer says that the home oxygen equipment is not medically necessary. Our physician reviewer found 
according to documentation from a prior hospitalization, the enrollee's measured oxygen level was 99% on 
room air. There was no documented visit with the patient's doctor as an outpatient to evaluate for any need for 
chronic use of oxygen supplementation to support this request. 
 
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 home oxygen equipment have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home oxygen equipment (E1390, E0431, E0443).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed. 
 
You asked the Plan to pre-approve the hospital bed. You say that the hospital bed is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary 
when at least one of the following criteria is met: 
 
1. The patient has a medical conditions which requires positioning of the body in ways not feasible with an 
ordinary bed; or 
 
2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate 
pain; or 
 
3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to 
congestive heart failure, chronic pulmonary disease, or problems with aspiration.  Pillows or wedges must have 
been considered and ruled out; or 
 
4. The patient requires traction equipment, which can only be attached to a hospital bed. 
 
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 hospital bed. Our reviewer says that 
a hospital bed is not medically necessary. Our physician reviewer found there is no documentation that the 
enrollee's condition requires positioning of the body; e.g., to alleviate pain, promote good body alignment, 
prevent contractures, or avoid respiratory infections- in ways not feasible in an ordinary bed; or that the 
enrollee's condition requires special attachments that cannot be fixed and used on an ordinary bed.  
 
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 hospital bed have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a hospital bed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Next-Generation Sequencing (NGS) genetic testing. 
 
You asked the Plan to pre-approve NGS genetic testing. You say that the requested genetic testing is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
genetic testing. 
 
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 NGS genetic testing. Our reviewer says 
that the enrollee does not meet criteria for the requested genetic testing. 
 Our physician reviewer found Next generation sequencing in endometrial cancer is covered for advanced or 
recurrent cancers. Based on the information provided this patient appears to have newly diagnosed disease and 
no stage is provided. For early stage endometrial cancer NGS is not indicated. The service is not reasonable or 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of NGS genetic testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Next-Generation Sequencing (NGS) genetic testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power mobility device (PMD). 
 
You asked the Plan to pre-approve a PMD. You say that the requested PMD is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for a PMD. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 a PMD. Our reviewer says that the 
enrollee does not meet criteria for a PMD. Our physician reviewer found the requested power mobility device 
is not medically necessary per Medicare National Coverage Determinations Manual, Section 280.3(B).  The 
documentation does not reveal that the enrollee has a personal mobility deficit but the documentation is not 
clear that it impairs participation in mobility related activities of daily living in the home. The enrollee's 
mobility deficit is currently helped by a walker. The documentation reveals no in person assessment in her 
home to evaluate that she can safely maneuver the PMD within the home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power mobility device (PMD).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve a seat lift mechanism. You say that the requested seal lift mechanism is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a seat 
lift mechanism. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed above 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 a seat lift mechanism. Our reviewer 
says that the enrollee does not meet criteria for a seat lift mechanism. Our physician reviewer found the 
documentation does not reveal objective evidence that the enrollee has severe arthritis of the hip. The 
documentation does not reveal that the enrollee has a neuromuscular disease. The documentation indicates no 
discussion of a seat lift mechanism on the 7/21 progress note. The documentation does not support that a seat 
lift is likely to affect improvement in the enrollee's condition or arrest or retard deterioration in the enrollee's 
condition. The records do not indicate that the enrollee is completely incapable of standing from a chair in the 
home on a physical exam. The records do indicate the enrollee can ambulate. The documentation does not meet 
the Medicare Local Coverage Determination (LCD) L33801, Seat Lift Mechanisms criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Lumbar 
Spine (72148). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only 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 MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found a detailed physical examination, differential 
diagnosis or plan of care pending the requested MRI results was not included. Reviewed documentation notes 
the enrollee was previously approved for a computed tomography study of the lumbar area. The results of this 
study were not available for review. Without the documentation, medical necessity cannot be determined. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Magnetic Resonance Imaging (MRI) of the Lumbar Spine (72148).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to further pay for the contact lenses provided on June 2, 2020. 
 
You asked the Plan to further pay for the contact lenses. You say that your sight could not be corrected with 
glasses or regular contacts. The Plan denied your request. The Plan says the payment completed your total $100 
allowance for contact lenses and eyeglasses. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. Your plan only covers contact lenses and eyeglasses up to $100 every 
calendar year. Once you have used the $100 allowance, you have exhausted the benefit for the lenses.  Based 
on this information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to further pay for the contact lenses provided on June 2, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve excision of tumor. 
 
You asked the Plan to pre-approve excision of tumor. You say that the requested excision of tumor is medically 
necessary. The Plan denied your request. The Plan says that the requested excision of tumor is not medically 
necessary. 
 
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 excision of tumor. Our reviewer says 
that the requested excision of tumor is medically necessary. Our physician reviewer found the enrollee is with a 
large right shoulder lipoma which has grown in size. Excision of tumor masses that clinically appear as lipomas 
is a standard of care to rule out malignancy. The requested excision of tumor is medically reasonable and 
necessary 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 excision of tumor have been met. Therefore, we decided that the Plan has to 
pre-approve excision of tumor.  
 
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 pay for the comprehensive periodontal evaluation, autogenous 
connective tissue graft procedure, and adjunctive procedure provided on April 27, 2020 and April 30, 2020. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation, autogenous connective tissue graft 
procedure, and adjunctive procedure. You say that you contacted the plan prior to the services being rendered, 
and were told that you had a $1,000 allowance to use toward any dental work. You also say that you were told 
that you could see any provider. The Plan denied your request. The Plan says the treating provider opted out of 
Medicare effective March 16, 2017 to March 16, 2021. The Plan also says that services performed by a 
privately contracted provider are not covered by the Plan. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the comprehensive periodontal evaluation, autogenous connective tissue graft procedure, and adjunctive 
procedure provided on April 27, 2020 and April 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of residual tooth roots provided on March 5, 
2020 by an OON provider. 
 
You asked the Plan to pay for the removal of residual tooth roots. You say that you were not informed that 
prior authorization was required for dental services. You also say that you had an infection, and this was 
provided as an emergency. The Plan denied your request. The Plan says the claim was processed at the fee 
schedule allowable of $60.50 and applied $1,390.00 to your liability. 
 
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 allowed amount of the service is 
$60.50 which applied toward the deductible. The contract also clearly states that you can get care from an out-
of-network dental provider, but you may pay more. Therefore, we decided that the Plan does not have to pay 
for the removal of residual tooth roots provided on March 5, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management services provided on January 13, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for pain management services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained 
by the facility or the provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for pain management services provided on January 
13, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from March 11, 2020 to 
March 16, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you are confident that the plan will 
concur this enrollee's care was medically necessary. You request reprocessing and payment of the claim per 
contract. The Plan denied your request. The Plan says that inpatient admission was not medically necessary as 
the enrollee could have been taken care of in an alternate level of care such as a short stay observation. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found per the documentation she was admitted to the hospital with symptoms of dizziness and fatigue 
due to acute anemia. She was discharged home on when considered medically stable. The review indicates that 
the record showed that at the time of inpatient admission the admitting physician reasonably expected that the 
patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 
 
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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from March 11, 2020 to March 16, 2020.  
 
 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasounds provided on January 11, 2020. 
 
You asked the Plan to waive the copayment for ultrasounds. You say that you believe you should be charged 
less for this service. The Plan denied your request. The Plan says the copayment you are being charged is 
correct. 
 
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 $155 
copayment for each Medicare-covered radiological diagnostic service, not including X-rays, performed in a 
physician's office or at a freestanding facility (such as a radiology center or medical clinic).  
 
You have been asked to pay $106 and $103.03 for two ultrasounds provided on January 11, 2020, which is less 
than your $155 copayment for each service. Your total copayment obligation is $209.03. Ultrasounds fall 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 ultrasounds provided on January 11, 2020.