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

We decided that the Plan does not have to pre-approve the implantation of neurostimulator electrode array. 
 
You asked the Plan to pre-approve the implantation of neurostimulator electrode array. You say that this 
service is clinically indicated and medically necessary. The Plan denied your request. The Plan says the 
member does not have a condition which warrants the medical necessity of this service. 
 
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 implantation of neurostimulator 
electrode array. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the member is not noted to have exhausted all other 
therapeutic modalities for their condition. Furthermore, there was no indication in the records provided for 
review that the member had been seen for a surgical consultation (regarding possible lumbar spine surgery). As 
the member has not exhausted all options to date, the requirements for coverage have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the implantation of neurostimulator electrode array have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the implantation of neurostimulator electrode 
array.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the chiropractic services. You say that you would like reconsideration 
because the member has experienced relief from previous chiropractic care. The Plan denied your request. The 
Plan says the requested provider is out-of-network and chiropractic services are only covered for manual 
manipulation of the spine to correct subluxation. 
 
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. Additionally, the request is for chiropractic 
services to treat migraines. The only chiropractic service Medicare covers is manual manipulation of the spine 
to correct subluxation. 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 medical services to be provided 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 August 18, 2020 to August 
21, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that coverage criteria has not been met. 
 
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 the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the patient's necessary hospital care (including earlier emergency and 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 August 18, 2020 to August 21, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Spravato. 
 
You asked the Plan to pre-approve Spravato. You say that the enrollee has previously tried and failed other 
medications. The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
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 Spravato. Our physician reviewer found 
that There is no documentation of treatment failure. There is no documentation of a PHQ 9 Depression rating 
scale. The documentation support that Spravato is medically reasonable and necessary 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 Spravato have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Spravato.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on August 4, 
2020. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that the provider who treated you 
took over your previous provider's practice. You also say that you confirmed that this provider was in-network 
with your plan. The Plan denied your request. The Plan says this service is 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 pay for the 
complete series of intraoral x-rays provided on August 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the vision exam you had on October 13, 
2020. 
 
You asked the Plan to waive the copayment. You say that this was a routine visit. The Plan denied your 
request. The Plan says the provider billed this as a medical visit. 
 
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 $40 
copayment for exams to diagnose and treat diseases and conditions of the eye.  
 
Review of the file shows that you had an eye exam on October 13, 2020. You have been asked to pay a $40 
copayment for the exam. the 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 the vision exam you had on October 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided. 
 
You asked the Plan to pay for the cardiovascular risk assessment testing. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare denies 
coverage for all cardiovascular risk assessment testing/panels, except the basic lipid panel, for symptomatic 
patients with suspected or documented cardiovascular disease. 
 
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 pay for the cardiovascular risk assessment testing. 
Our reviewer says that this service is not medically reasonable and necessary. Our physician reviewer found in 
this setting, screening genetic risk panel testing has not been shown to improve cardiac outcome incremental to 
that achievable based on treatment guided by standard clinical risk profiling and basic lipid analysis alone. 
 
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 cardiovascular risk assessment testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on March 16, 2020. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services 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, to be covered in-network, you need to 
use a provider that is contracted with the Plan's dental vendor. The file shows the provider is not part of the 
Plan's dental vendor. Therefore, we decided that the Plan does not have to pay for the dental services provided 
on March 16, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the sleep study (95811) provided on August 31, 2020. 
 
You asked the Plan to pay for the sleep study. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says that there is no evidence of a face-to-face evaluation. 
 
The Plan follows Medicare rules. Medicare rules say that repeat polysomnography or sleep testing for 
diagnosing sleep apnea requires documentation justifying the medical necessity for the repeated test. 
 
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 sleep study. Our reviewer says that in 
this case, the enrollee has a history of sleep apnea and has been treated with nasal CPAP, he was evaluated by a 
sleep disorder specialist who has recommended a repeat overnight study Polysomnography; sleep staging with 
4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or 
bilevel ventilation, attended by a technologist. Our physician reviewer found the member meets LCD criteria 
for coverage of the sleep study. 
 
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 sleep study have been met. Therefore, we decided that the Plan has to pay 
for the sleep study (95811) provided on August 31, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
August 18, 2020 to August 23, 2020. 
 
You asked the Plan to pay for home health services. You say that this was billed correctly. The Plan denied 
your request. The Plan says this was not billed with a valid HIPPS code. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the HIPPS 
code is invalid. Beginning on January 1, 2020, the formatting for HIPPS codes changed. Therefore, we decided 
that the Plan does not have to pay for the home health services provided to the enrollee from August 18, 2020 
to August 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided from June 8, 2020 to June 
10, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or 
hospital for services furnished to the beneficiary while an inpatient.  
 
We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during 
an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided from June 8, 2020 to June 10, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine (90750) provided on April 28, 2020. 
 
You asked the Plan to pay for the shingles vaccine. You say that you would like reconsideration because this 
service is covered by Medicare. The Plan denied your request. The Plan says this service is not covered under 
Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine (90750) provided on 
April 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure provided on July 22, 2020. 
 
You asked the Plan to pay for the preventive procedure. You say that prior to your appointment you confirmed 
with the Plan that this dentist was in-network. You also say that when you arrived at your rescheduled 
appointment you were advised that this provider was no longer in-network. The Plan denied your request. The 
Plan says this service is 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 pay for the 
preventive procedure provided on July 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral exam (D0140), cone beam computed 
tomography (CT) capture (D0364, and periapical radiographic image (X-Ray) (D0220) provided on August 5, 
2020. 
 
You asked the Plan to pay for a limited oral exam, cone beam CT capture and periapical X-Ray. You say that 
the services should be covered. The Plan denied your request. The Plan says you have exhausted the benefit 
frequency limit for periapical X-Rays and the other services are not covered under your plan. 
 
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. Specifically, records indicate you have already received a periapical 
X-Ray for the 2020 plan year. This means the service is not covered. Also, a limited oral exam and cone beam 
CT capture are not listed in the Plan?s benefit chart. This means these services are also not covered. Therefore, 
we decided that the Plan does not have to pay for a limited oral exam (D0140), cone beam computed 
tomography (CT) capture (D0364, and periapical radiographic image (X-Ray) (D0220) provided on August 5, 
2020.
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 you would like reconsideration because the 
shower chair will provide you with safety and stability in the shower. The Plan denied your request. The Plan 
says the shower chair is not a Medicare 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says coverage rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that continuous glucose monitors are covered for 
enrollees who are insulin-treated with multiple (three or more) daily injections of insulin.  
 
We looked at the file and Medicare rules. The record does not show that the enrollee uses insulin three or more 
times daily. 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.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services to be provided by an out of 
network provider. 
 
You asked the Plan to pre-approve home health services. You say that the enrollee was referred for home 
health services by their primary doctor. You say that the enrollee needs physical therapy and occupational 
therapy for a diagnosis of cervicogenic headache, occipital neuralgia and neck pain. The Plan denied your 
request. The Plan says the provider is not a network provider with the Plan. 
 
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 services to be provided by an out of network provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for elective cardioversion (92960) provided on May 1, 2020. 
 
You asked the Plan to pay for the elective cardioversion. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support the service billed. 
 
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 92960 is cardioversion, elective, electrical conversion of 
arrhythmia; external. 
 
We asked our coder 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 elective cardioversion. Our reviewer says that CPT code 
92960 does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative 
report did not include sufficient documentation to confirm that, elective cardioversion as a distinct service.  
CPT 92960 describes external cardioversion only.  Because cardioversion is commonly necessary during 
electrophysiologic procedures and is considered an inclusive component not warranting additional reporting. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the elective cardioversion have not been met. Therefore, we decided that the 
Plan does not have to pay for elective cardioversion (92960) provided on May 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the static progressive stretch knee device (E1811) provided 
on July 2, 2020, through August 2, 2020. 
 
You asked the Plan to pay for the static progressive stretch knee device. You say that you would like 
reconsideration because this is not a continuous passive motion device and is medically necessary. The Plan 
denied your request. The Plan says this device is only covered after knee replacement surgery for a three-week 
period. 
 
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 pay for the static progressive stretch knee device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the literature does not reveal that the addition of the JAS devices 
significant improves patient clinical outcomes therefore this is not proven to be effective or the standard of care 
for this member's condition. 
 
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 static progressive stretch knee device have not been met. Therefore, we 
decided that the Plan does not have to pay for the static progressive stretch knee device (E1811) provided on 
July 2, 2020, through August 2, 2020.