Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve home health care services to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. 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 
home health care services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mammogram (77067) provided December 11, 2017. 
 
You asked the Plan to pay for the mammogram. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the code billed is not payable. 
 
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 code 77067 is not supported in the medical record. Specifically, per the 2017 National 
Physician Fee Schedule, CPT code 77067 is marked with a status of "I". This code is not valid for Medicare 
purposes. Based on this information, we decided that Medicare rules for coverage of the mammogram have not 
been met. Therefore, we decided that the Plan does not have to pay for a mammogram (77067) provided 
December 11, 2017.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you have used all 12 one-way trips for the 
2020 benefit year and additional trips will not be approved. 
 
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 12 one-way transportation 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.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on May 15, 2020. 
 
You asked the Plan to pay for the diagnostic radiology services. 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 
services at issue. 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 diagnostic radiology services provided on May 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on March 9, 2020. 
 
You asked the Plan to pay for drug test. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because the documentation 
submitted does not include a valid physician order, lab requisition, or medical records stating exactly which 
tests were to be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided 
that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing provided on March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. You say that this provider is close to your home 
and it is difficult to travel further away. The Plan denied your request. The Plan says the services are available 
within the primary network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression garments identified with codes S8425 and 
S8423. 
 
You asked the Plan to pre-approve the compression garments. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that compression garments described by codes S8425 and 
S8423 are noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
garments identified with codes S8425 and S8423.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0553). 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that the CGM 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 a CGM is covered when the beneficiary is 
insulin-treated with multiple (three or more) daily injections. 
 
We looked at the file and Medicare rules. The record does not show that the enrollee is treated with insulin 
injections. Based on this information, we decided that Medicare rules for coverage of a continuous glucose 
monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ankle/foot orthosis (L4396) to be provided by an out 
of network (OON) provider. 
 
You asked the Plan to pre-approve the orthosis. You say that the requested provider is closer to your home. The 
Plan denied your request. The Plan says Durable Medical Equipment is only covered when obtained 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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the ankle/foot orthosis (L4396) 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 the physician's services. 
 
You asked the Plan to pre-approve the physician's services. You say that the enrollee has been under your care 
since June of 1998 for a spinal cord injury. You say that it would be a disservice for the enrollee to begin with a 
new physician who is not familiar with his history and does not have a relationship with him. The Plan denied 
your request. The Plan says the enrollee is required to utilize in-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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
physician's services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0553). 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary. The Plan denied 
your request. The Plan says rules for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that a CGM is covered when the beneficiary is 
insulin-treated with multiple (three or more) daily injections.  
 
We looked at the file and Medicare rules. The record shows the enrollee is not currently insulin treated with 
daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous 
glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array; peripheral nerve (excludes sacral nerve) (CPT Code 64555) and implantable neurostimulator, pulse 
generator, any type (CPT Code L8679). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says Electrical stimulation of auricular acupuncture points (also known as 
electro-acupuncture stimulation) is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, auricular peripheral nerve stimulation will be denied 
as non-covered. This service is not a covered Medicare benefit because acupuncture for auricular stimulation 
does not meet the definition of reasonable and necessary under Section 1862(a)(1) of the Act. Any current or 
future devices when used for auricular peripheral nerve stimulation or electro-acupuncture would be considered 
a non-covered service. Therefore, we decided that the Plan does not have to pre-approve percutaneous 
implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (CPT Code 64555) 
and implantable neurostimulator, pulse generator, any type (CPT Code L8679).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing. 
 
You asked the Plan to pre-approve periodontal scaling and root planing. You say that you need this procedure 
because you are losing teeth due to the tarter and dirt under the gum line. You say that if this procedure isn't 
done you will lose teeth. 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 Plans 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 
periodontal scaling and root planing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0553). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the CGM is medically 
necessary. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a CGM is covered when the beneficiary is 
insulin-treated with multiple (three or more) daily injections.  
 
We looked at the file and Medicare rules. The record shows the enrollee is not currently insulin treated with 
daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous 
glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) (K0553).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for bronchoscopic placement endobronchial valves (EBV) and an inpatient 
admission for the enrollee. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is not enough evidence that this is a safer alternative to lung volume reduction 
surgery. 
 
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 the services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found the enrollee has severe COPD with emphysema, and severe air trapping. Placement of EBV is a less 
invasive way of accomplishing lung volume reduction, with benefits similar to surgical lung reduction, which 
is covered by Medicare. Multiple randomized, high quality clinical studies have demonstrated the benefits and 
risks of the procedure, and it is now accepted as having a role in the treatment of COPD for certain patients. 
The enrollee meets the clinical requirements for the procedure. The procedure requires a minimum 3-day in-
hospital stay because of the substantial risk for pneumothorax in the few days after the procedure. 
Pneumothorax can be life-threatening for patients with severe COPD if not quickly treated, and hospitalization 
makes that treatment immediately available if needed. It is widely accepted that the procedure should not be 
performed without hospitalization. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
bronchoscopic placement endobronchial valves (EBV) and an inpatient admission for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat back cushion (E1399). 
 
You asked the Plan to pre-approve a seat back cushion. You say that you need this and Medicaid will not cover 
it. The Plan denied your request. The Plan says this is not covered under Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a seat back cushion (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. 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. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system (E2300). You say that you would like the 
Plan to reconsider their denial. The Plan denied your request. The Plan says a power seat elevation system 
(E2300) is statutorily non-covered by Medicare and the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare specifically excludes coverage of power seat elevation 
systems coded as E2300. Based on this information, we decided that Medicare rules for coverage of a power 
seat elevation system (E2300) have not been met. Therefore, we decided that the Plan does not have to pre-
approve a power seat elevation system (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extractions and consultation to be provided by an 
oral surgeon. 
 
You asked the Plan to pre-approve the extractions and consultation. You say that you have a bad infection and 
needs the problem resolved. The Plan denied your request. The Plan says dental 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services performed by oral 
surgeons are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve the extractions and consultation to be provided by an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. 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 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical 
record supports a need for physical and occupational therapy but it does not support a need for an intensive 
rehabilitation therapy program. There is not a reasonable expectation that this enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.