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

We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that experimental and investigational procedures are not covered by 
Medicare. 
 
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 requested services are not considered medically reasonable and necessary in this case. The spacer is 
experimental. More research is needed to show the safety and efficacy of the device. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Vertiflex Superion device placement surgery for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve legrests with center mount assembly (K0108), calf pads 
(E0955), a positioning back cushion (E2620), and a combination skin protection/positioning seat cushion 
(E2607) to be provided with an approved power wheelchair. 
 
You asked the Plan to pre-approve the requested components of a power wheelchair. You say that all requested 
items should be approved. The Plan denied your request. The Plan says two of the requested codes are included 
in payment for the initial issue of the wheelchair. The requested cushions are not shown to be medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that positioning seat/back cushions are covered only when 
the enrollee has postural asymmetries.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested components of a power 
wheelchair. Our reviewer says that the requested back and seat cushions are not considered medically 
necessary based on Medicare guidelines.  
 
 
Our physician reviewer found the patient does not have any significant postural asymmetries therefore the 
criteria for the positioning back cushion coded as E2620 and the combination skin protection/positioning seat 
cushion coded as E2607 have not been met. 
 
The legrest assembly and calf pads are also not separately approved as the items described by these codes are 
included in coverage of the wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested components of a power wheelchair have not been met. Therefore, 
we decided that the Plan does not have to pre-approve legrests with center mount assembly (K0108), calf pads 
(E0955), a positioning back cushion (E2620), and a combination skin protection/positioning seat cushion 
(E2607) to be provided with an approved power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex superion device placement surgery for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that this treatment is considered safe and effective. 
The Plan denied your request. The Plan says that experimental and investigational procedures are not covered 
by Medicare. 
 
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 requested services are not considered medically reasonable and necessary in this case. The spacer is 
experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Vertiflex superion device placement surgery for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Creon DR. 
 
You asked the Plan to pre-approve this drug. You say that you require this drug to help breakdown your food. 
The Plan denied your request. The Plan says that this is not covered under Part B. 
 
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 Creon DR.  
 
Benefits for this drug 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection, diagnostic or therapeutic agent, paravertebral 
facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar 
or sacral (64493) injection, anesthetic agent and/or steroid (64450x3) 
 
You asked the Plan to pre-approve spinal injections. You say that you ask for reconsideration for approving the 
sacral lateral branch blocks so that you can continue to provide non-opioid therapies for this enrollee. The Plan 
denied your request. The Plan says there is not enough proof to support that this procedure can be effective in 
giving results to help with treatment. 
 
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 spinal injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found RFA of the lateral sacral branches is an experimental/ investigational procedure. Therefore, the 
request is deemed not medically reasonable or 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 spinal injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve injection, diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or 
nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral (64493) injection, 
anesthetic agent and/or steroid (64450x3)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lead wires (A4557) provided on September 30, 2020. 
 
You asked the Plan to pay for lead wires. You say that this should be covered. The Plan denied your request. 
The Plan says the replacement of lead wires at this interval is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement of lead wires (A4557) more often 
than every 12 months would rarely be reasonable and necessary. 
 
We looked at the file and Medicare rules. The record shows that the enrollee received a TENS machine less 
than 12 months prior to receiving the lead wires at issue. There is no justification in the records as to why it is 
reasonable and necessary to replace the lead wires at this frequency. Based on this information, we decided that 
Medicare rules for coverage of lead wires have not been met. Therefore, we decided that the Plan does not have 
to pay for lead wires (A4557) provided on September 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental items. You say that you are having problems with your dentist. 
You say that you need bottom dentures. You say it was denied because you received bottom dentures in 2017. 
You say that if you do not get bottom dentures then you will have no teeth. You also say that you need dentures 
as soon as possible because you cannot eat and have a lot of discomfort. The Plan denied your request. The 
Plan says dentures are covered once every five calendar years. The Plan also says that the frequency limit has 
been reached. 
 
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 frequency limit of dentures once 
every five calendar years has been reached. The record shows that the Plan paid for dentures that you received 
on April 30, 2018, less than five years ago. Therefore, we decided that the Plan does not have to pre-approve a 
complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for bone mass measurements provided on 
June 23, 2020. 
 
You asked the Plan to waive the coinsurance for bone mass measurements. You say that you were not aware 
that the provider is out-of-network. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct amount. 
 
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 50% 
coinsurance for out-of-network bone mass measurements.  
 
You received bone mass measurements at an out-of-network provider on June 23, 2020. Therefore, you are 
responsible to pay your share of the out-of-network cost-sharing charges. The allowed amount is $44.48 and 
50% of that is $22.24.  
 
You have been asked to pay the total coinsurance amount of $22.24 for bone mass measurements. Bone mass 
measurements fall within the bone mass measurement 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 
coinsurance for bone mass measurements provided on June 23, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve twelve additional fractions of intensity-modulated radiation 
therapy (IMRT). 
 
You asked the Plan to pre-approve the additional fractions. You say that this is medically necessary. The Plan 
denied your request. The Plan says that 28/40 fractions can be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the additional fractions. Our reviewer 
says that the requested additional fractions are considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee, with favorable risk prostate cancer, was offered definitive radiotherapy 
with IMRT/IGRT in 40 fractions?.  At issue is the number of fractions requested (n=40). The insurance form 
specifies 23 fractions for phase 1 and 17 for phase 2; the dose is not specified. A total of 28 fractions are 
approved and the remainder are disputed here. For prostate cancer, NCCN guidelines (v2.2021) offer as 
preferred dose fractionations: 3 Gy x 20, 2.7 Gy x 26, 2.5 Gy x 28. Conventional fractionation remains an 
acceptable alternative 1.8-2 Gy for 37-45 fractions. So for this case, the issue is the appropriateness of 40 
fractions vs. moderate hypofractionation. Treatment with more fractions is costlier, which is the root of the 
dispute. However, 40 fractions in considered acceptable (albeit not preferable) by NCCN guidelines and 
ASTRO, ASCO, and AUA Evidence-Based Guideline ? with the expert guidelines acknowledging some 
limitations in the data.  The radiation oncologist is choosing 40 fractions based on the large prostate size (which 
is not based in strong evidence, but a rational concern to justify conventional fractionation). 
 
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 additional fractions have been met. Therefore, we decided that the Plan has 
to pre-approve twelve additional fractions of intensity-modulated radiation therapy (IMRT).  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve radiofrequency ablation of the right greater saphenous vein 
(36475). 
 
You asked the Plan to pre-approve radiofrequency ablation of the right greater saphenous vein. You say that 
this is medically necessary. The Plan denied your request. The Plan says that the criteria for coverage have not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that thermal ablation (radiofrequency or laser) will be 
considered medically reasonable and necessary for ablation of incompetent saphenous veins for the treatment 
of patients with symptomatic CEAP clinical classification C2 to C6 disease. 
 
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 radiofrequency ablation of the right 
greater saphenous vein. Our reviewer says that the criteria for coverage have been met. Our physician reviewer 
found the records show that the right greater saphenous vein measurements range from 4.0 mm to 6.6 mm, and 
reflux is present. Spider veins and hyperpigmentation are documented. It is documented that the enrollee is 
symptomatic and fits the criteria for clinical stage CEAP 4 classification. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablation of the right greater saphenous vein have been met. 
Therefore, we decided that the Plan has to pre-approve radiofrequency ablation of the right greater saphenous 
vein (36475).  
 
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 pre-approve four periodontal scalings and root planings to be 
rendered by an OON provider. 
 
You asked the Plan to pre-approve the scalings and planings. You say that you feel that this service should be 
covered. The Plan denied your request. The Plan says services provided by an OON or non-contracted provider 
are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve four 
periodontal scalings and root planings to be rendered by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6545 
. 
You asked the Plan to pre-approve the compression stockings. You say that you would like reconsideration 
because your cardiologist prescribed you thigh length compression stockings due to vascular insufficiency. The 
Plan denied your request. The Plan says your medical notes do not say that you have open sores on your legs 
from surgery. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6545 
 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 
stockings identified with code A6545 
.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 2, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 
physician's 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 physician's services provided on October 2, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on July 4, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider submitted the claim after timely filing limitations. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until September 14, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the services provided to the enrollee on July 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that it is difficult to get up. The Plan denied your 
request. The Plan says the item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99222) provided on July 17, 2019. 
 
You asked the Plan to pay for hospital care. You say that these medically necessary services were provided to 
the enrollee in good faith and you are entitled to reimbursement for the services rendered. The Plan denied your 
request. The Plan says rules for payment have not been met. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for hospital care was not filed until September 24, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for hospital care (99222) provided on July 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that you require the device. The Plan denied your 
request. The Plan says Ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in 
this RAD policy will be denied as not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
coverage criteria for a home ventilator are not met. Our physician reviewer found the enrollee has COPD and 
has had a home ventilator since December 16, 2019.  However, it appears that Medicare criteria for coverage of 
a home ventilator were not met at that time.  There is no documentation of CO2 retention on arterial blood gas 
testing while stable.  There has been no documented failure of BiPAP.  The AVAPS-AE mode currently being 
provided by the ventilator can be provided by certain BiPAP devices, at less cost.  Medicare does not cover a 
ventilator when being used as BiPAP.  Battery backup and alarms are not medically necessary, because the 
patient is not at risk for immediate harm if ventilator support stopped.  A home ventilator is not medically 
necessary, and the denial is upheld. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.