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

 
We decided that the Plan does not have to waive the copayment for physical therapy provided by a 
participating provider on June 23, 2020, to September 2, 2020. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you think this should be waived 
because of Covid-19. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for outpatient rehabilitation services/in-network/physical therapy.  
 
You have been asked to pay a $40 copayment for each physical therapy session. The total amount you are 
being asked to pay is $280 ($40 x 7 sessions = $280). Physical therapy falls within the outpatient rehabilitation 
services/in-network/physical therapy 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 
physical therapy provide by a participating provider on June 23, 2020, to September 2, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says needs are not skilled. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found based on the 
medical records provided, there is no documentation that skilled nursing services are required to effectively 
provide treatment, care, and/or services in order to improve your condition, or to establish/perform a 
maintenance program to maintain your condition and/or prevent deterioration. You required skilled nursing 
services in August and September 2020 when you had a Foley catheter and a urinary tract infection but the 
 
 
catheter has been removed. Records indicate some urinary leakage after the catheter removal but no other 
subsequent acute urinary symptoms or other unstable medical issues requiring skilled nursing 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 27, 2020 to July 8, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you had a referral from your neurosurgeon.  
There were no office visits available with this provider for a long time, so you set up appointments with his 
colleague.  You say that since you had a referral, this should be covered. The Plan denied your request. The 
Plan says you did not have a referral to see this doctor.  This doctor is not in your Plan and the Plan did not 
authorize care with this 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 provider in this case is not a network provider with the Plan. You did not have authorization from the Plan 
to see this specific provider.  You may have had a referral for a single visit with this provider's colleague, but 
you did not have authorization to see the doctor who you actually saw, and you did not have authorization for 
multiple visits. 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 the medical services provided on May 27, 2020 to July 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular radiofrequency (RF) ablation using a 
neurolytic agent. 
 
You asked the Plan to pre-approve RF ablation. You say that you are appealing. The Plan denied your request. 
The Plan says the denial of authorization is correct, because this method of radiofrequency ablation is 
considered experimental/investigational and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation using a chemical agent is 
not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of RF ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
genicular radiofrequency (RF) ablation using a neurolytic agent.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and related accessories. 
 
You asked the Plan to pre-approve the requested items. You say that the upgrade is free to the enrollee. The 
Plan denied your request. The Plan says the enrollee does not qualify for the requested wheelchair base. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair is only covered under 
certain medical indications.  
 
The file shows that a group 3 power wheelchair with an expandable control system was requested. We looked 
at the file and the rules. The documentation shows that the enrollee has a history of diabetes, osteoarthritis, 
COPD, cervical spondylosis, and back pain. The file does not show that the enrollee has a mobility limitation 
that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that 
the Plan does not have to pre-approve a Group 3 power wheelchair and related accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoscopic decompression of spinal cord, nerve root(s), 
including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated 
intervertebral disc, 1 interspace, lumbar (CPT Code 62380). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the 
relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found transforaminal endoscopic discetomy is experimental. More research is 
needed to show safety and efficacy. Open surgery is the gold standard. 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 not been met. Therefore, we decided that the Plan does not have to pre-approve endoscopic 
decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, 
discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar (CPT Code 62380).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiological examination provided on April 25, 2019. 
 
You asked the Plan to pay for the radiological examination. You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says they were not your primary payer on this date of service. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the radiological examination until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for the radiological examination provided on April 25, 2019.
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 the enrollee meets the 
criteria for this device, and it is medically necessary. The Plan denied your request. The Plan says the denial of 
authorization for this device is correct, because there is no documentation showing that at least 4 weeks of 
regular, daily, multiple-hour home usage of an E0650 or E0651 device. 
 
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 an oxygen concentrator, and a portable oxygen system. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you 
have exhausted your benefit. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you already have oxygen equipment. The oxygen equipment you have serves the same 
purpose as the requested items. The records do not show that you have had your equipment for 5 or more years. 
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an oxygen concentrator, and a portable oxygen system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep gum and root cleaning (D4341). 
 
You asked the Plan to pre-approve deep gum and root cleaning. You say that the service is medically 
necessary. 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. The plan covers limited 
preventative and diagnostic dental services, but additional dental care is available for purchase under Optional 
Supplemental Benefits. 
 
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, you did not purchase the additional supplemental dental 
benefits. Therefore, we decided that the Plan does not have to pre-approve deep gum and root cleaning 
(D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the extraction of erupted tooth or exposed root tooth 
(D7140). 
 
You asked the Plan to pre-approve the extraction of erupted tooth or exposed root tooth. You say that the 
services are medically necessary for the enrollee. The Plan denied your request. The Plan says the services you 
are requesting are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
extraction of erupted tooth or exposed root tooth (D7140).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a life alert system. 
 
You asked the Plan to pre-approve a life alert system. You say that the enrollee needs an alert system. The Plan 
denied your request. The Plan says an alert system is a device that is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. A life alert system is an emergency communications system which does not serve a 
diagnostic or therapeutic purpose and is excluded from coverage by Medicare. 
  
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 life alert system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain crown (D2740 x 2) and core build up 
(D2950 x 2). 
 
You asked the Plan to pre-approve the crowns and core build up. You say that the services are medically 
necessary. The Plan denied your request. The Plan says crowns are not listed as covered services. The Plan says 
core build up is not listed as covered either. 
 
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 a 
porcelain crown (D2740 x 2) and core build up (D2950 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of impacted tooth (D7230), primary closure 
of sinus perforation (D7261), and incisional biopsy of oral tissue (D7285). 
 
You asked the Plan to pre-approve the removal of impacted tooth, primary closure of sinus perforation, and 
incisional biopsy of oral tissue. You say that the services you are requesting is medically necessary. The Plan 
denied your request. The Plan says these services are not covered under your benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
removal of impacted tooth (D7230), primary closure of sinus perforation (D7261), and incisional biopsy of oral 
tissue (D7285).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power elevation system (E2300), expandable 
controller (E2377, E2313, E2311), and color, light, and reach kits (K0108) for a power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that the accessories are medically 
necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
 
The Plan follows Medicare rules. Medicare rules say that Seat Elevation features are non-covered. Expandable 
controllers are only covered when medically necessary. Items that are not primarily medical in nature 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 wheelchair accessories. Our 
reviewer says that the expandable controller is not medically necessary. Our physician reviewer found based on 
the medical records provided the enrollee has 3/5 upper extremity strength and is able to feed and groom 
himself with set-up assistance, thus he is able to operate the standard switches for the approved functions. 
 
We looked at this physician's review, the file, and Medicare rules. The expandable controller is not medically 
necessary. The Color, Light, and Reach kits are not primarily medical in nature and are non-covered. Power 
Elevation systems are not a covered item. Based on this information, we decided that Medicare rules for 
coverage of the wheelchair accessories. have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power elevation system (E2300), expandable controller (E2377, E2313, E2311), and color, 
light, and reach kits (K0108) for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling and root planing (D4341) for the upper right 
quadrant. 
 
You asked the Plan to pre-approve the dental service. You say that you are diabetic. You say that you need this 
service because your gum will not heal. The Plan denied your request. The Plan says the requested service is 
dental in nature. The Plan says that dental services are not covered. 
 
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 your teeth or the structures directly supporting your 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 scaling and root 
planing (D4341) for the upper right quadrant.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan of the chest, abdomen, and pelvis for the 
enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not reasonable and necessary under Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found per NCCN guidelines 
Version 4. 2020 CT surveillance for Marginal Zone lymphoma Stage IV B is recommended annually if there is 
no sign of recurrence after 2 years of surveillance.  As such annual scans are due. The Stage 0 
DCIS for which the patient was treated in September 2020 does not provide an indication for CT of the chest, 
abdomen and pelvis per NCCN guidelines. These guidelines recommend clinical monitoring as 
well as mammographic follow-up at 6 month intervals. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CT scan of the chest, abdomen, and pelvis for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device. 
 
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction 
device, without open decompression or fusion, including image guidance when performed, lumbar; single level 
(22869). You say that the enrollee is suffering from debilitating disease. The Plan denied your request. The 
Plan says a review of the current medical literature indicates that this service is considered experimental and 
investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Insertion of interlaminar/interspinous 
process stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (22869). Our reviewer says that the requested services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. 
More research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Insertion of interlaminar/interspinous process stabilization/distraction device, 
without open decompression or fusion, including image guidance when performed, lumbar; single level 
(22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of 
interlaminar/interspinous process stabilization/distraction device.