Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for lab services provided on November 7, 2019. 
 
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan 
denied your request. The Plan says that this testing is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request.  The case file submitted by the Plan did not indicate why these 
services are not covered by Medicare. The case file contained no medical records and insufficient information 
as to who ordered the services provided. We are unable to substantiate the Plans denial for payment of this 
service. Therefore, we decided that the Plan has to pay for lab services provided on November 7, 2019.  
 
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 life alert system. 
 
You asked the Plan to pre-approve a life alert system. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says a life alert system is not covered by Medicare or the Plan. 
 
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 life alert system.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on May 22, 2020. 
 
You asked the Plan to pay for the genetic testing. You say that you would like reconsideration because this test 
was medically necessary and will directly impact the member's medical management. The Plan denied your 
request. The Plan says this coding is not supported by Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, the genetic testing, was requested solely for screening purposes. The 
documentation does not show that the requested pharmacogenomic testing was ordered due to any 
signs/symptoms of a drug reaction. There is no evidence that the testing was provided for therapeutic decision-
making regarding the need for the use of any specific drug. This means that this extended panel was provided 
for screening purposes, and this type of testing is not among those covered by Medicare for screening 
Therefore, we decided that the Plan does not have to pay for genetic testing provided on May 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says you do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific 
criteria are met. 
 
We looked at the file and Medicare rules. There is no documentation in the submitted records that you check 
your blood sugars at least four times daily. 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 
a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist services. You say that you would like to continue to see this 
provider. The Plan denied your request. The Plan says there are in-network providers available for these 
services. 
 
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 
specialist services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the brain (70553).
You asked the Plan to pre-approve an MRI of the brain. You say that the services are necessary. The Plan
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been
met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically
necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve an MRI of the brain. Our reviewer says
that the services are medically necessary. Our physician reviewer found an MRI of the brain for chest cavity
malignant staging is standard in the workup for metastatic disease. Metastases may be present without causing
current symptomatology. The positron emission tomography/computed tomography (PET/CT) scan would not
encompass analysis for brain metastases therefore the request for MRI of the brain is reasonable and medically
necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an MRI of the brain have been met. Therefore, we decided that the Plan has to
pre-approve a magnetic resonance imaging (MRI) of the brain (70553).
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 a lower partial denture. 
 
You asked the Plan to pre-approve the lower partial denture. You say that you really need to get this new 
partial and you do not have the one that was made in 2016. The Plan denied your request. The Plan says since 
you were provided with a partial denture within the last five years, the benefit for this service is currently 
exhausted. 
 
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, coverage for dentures is only available 
once every five years. The file shows that the Plan covered an upper and partial lower denture on December 22, 
2016. Because five years have not elapsed since that date, your denture benefit remains exhausted at this time. 
Therefore, we decided that the Plan does not have to pre-approve a lower partial denture.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an inpatient level of care. 
 
You asked the Plan to pre-approve an inpatient level of care. You say that the requested inpatient level of care 
is medically necessary. The Plan denied your request. The Plan says that the requested inpatient level of care is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an inpatient level of care. Our reviewer 
says that the requested inpatient level of care is medically necessary. Our physician reviewer found the review 
indicates that the enrollee was being treated for dementia, hypertension, and hyperlipidemia on the older adult 
behavioral health unit, when she tested positive for COVID 19. The enrollee is mildly dyspneic. The enrollee 
was not hypoxic, but had slight fever. The enrollee's vitals on November 30, 2020 included temperature from 
98.9 to 101.2F, heart rate at 50, and blood pressure at 125/60. On December 2, 2020, the enrollee's temperature 
was 97.5, heart rate was 60, and blood pressure was 161/66. The review has determined that the requested 
inpatient level of care is medically reasonable and necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient level of care have been met. Therefore, we decided that the Plan 
has to pre-approve an inpatient level of care.  
 
 
 
 
 
 
 
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 Repatha SureClick. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Repatha SureClick.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the two crowns (D2740 x2) provided on May 12, 2020. 
 
You asked the Plan to pay more for the crowns. You say that the provider refused to accept the Plan's approved 
cost for the crown procedures. You also believe the Plan should have paid an additional $138 for each crown. 
The Plan denied your request. The Plan says you received upgraded zirconia crowns, which are not a covered 
benefit. The Plan also says that rather than denying the zirconia crowns outright, the Plan has allowed the 
crowns at the rate of basic porcelain/ceramic crowns, and has paid its share. 
 
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, you are responsible for a 50% 
coinsurance for each crown (D2740). The record shows that you signed a treatment plan acknowledging that 
you would be responsible for the financial responsibility for all charges. Therefore, we decided that the Plan 
does not have to pay more for the two crowns (D2740 x2) provided on May 12, 2020.  
 
Your complaint about the possible unprofessionalism of the provider is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint nerve radiofrequency neurolysis (64635). 
 
You asked the Plan to pre-approve facet joint nerve radiofrequency neurolysis. You say that this is medically 
necessary. The Plan denied your request. The Plan says the enrollee did not have sufficient pain relief. 
 
The Plan must follow Medicare rules. Medicare rules say that the destruction of cervical, thoracic or lumbar 
paravertebral facet joint (median branch) nerves will not be considered medically reasonable and necessary 
when the medical records do not support that the patient experienced temporary or prolonged abolition of the 
pain after a facet joint nerve block injection. 
 
We looked at the file and Medicare rules. While the record shows that the enrollee had some pain relief 
following a facet joint nerve block injection, the records do not support that the enrollee experienced temporary 
or prolonged abolition of the pain. Based on this information, we decided that Medicare rules for coverage of 
facet joint nerve radiofrequency neurolysis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint nerve radiofrequency neurolysis (64635).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a panniculectomy. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a panniculectomy is covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says 
that the services are medically necessary. Our physician reviewer found the enrollee has clear evidence of a 
functional impairment related to an abdominal pannus. She is noted to have excess soft tissue after 
significant weight loss. She has attempted to treat her functional impairment of chronic rashes with 
antifungal medications. Although the most recent evaluation that documents her chronic rashes is from 
2018, the enrollee's statements clearly show that she continues to have significant functional impairment. 
Given her clinical history, one would not expect this to resolve on its own. The panniculectomy is 
reasonable and medically necessary at this time. 
 
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 been met. Therefore, we decided that the Plan has 
to pre-approve a panniculectomy.  
 
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: Partially Favorable

We decided that the Plan has to pre-approve an insulin pump. We decided that the Plan does not have to preapprove
an insulin pump infusion set, insulin pump syringes, a continuous glucose monitor transmitter and a
continuous glucose monitor transmitter sensor.
You asked the Plan to pre-approve an insulin pump. You say that this is medically necessary for the enrollee.
The Plan says that that the enrollee's c-peptide levels are not outside the normal range.
We decided that the Plan has to pre-approve an insulin pump.
The Plan follows Medicare rules. Medicare rules say that an insulin pump is covered when the criteria listed
above have been met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve an insulin pump. Our reviewer says that
an insulin pump is medically reasonable and necessary for the enrollee in this case. This patient has
complicated diabetes and requires frequent administration and monitoring of blood sugar. This would be the
exception in the Type 2 diabetes patient that insulin pump and CGM would be indicated. Our physician
reviewer found that the enrollee's condition meets criteria for coverage of an insulin pump.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an insulin pump have been met. Therefore, we decided that the Plan has to preapprove
an insulin pump.
We also decided that the Plan does not have to pre-approve an insulin pump infusion set, insulin pump
syringes, a continuous glucose monitor transmitter or a continuous glucose monitor transmitter sensor.
The Plan follows Medicare rules. Medicare rules say that an insulin pump infusion set, insulin pump syringes, a
continuous glucose monitor transmitter and a continuous glucose monitor transmitter sensor are not covered by
Medicare.
We looked at the file and Medicare rules. Therefore, we decided that the Plan does not have to pre-approve an
insulin pump infusion set, insulin pump syringes, a continuous glucose monitor transmitter and a continuous
glucose monitor transmitter sensor.
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar fusion. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that lumbar fusion is covered when specific criteria 
are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis. 
There is no documented spinal stability. The criteria for lumbar fusion are not met and the services are not 
reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar fusion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CS4 cardio strider (A9300). 
 
You asked the Plan to pre-approve a CS4 cardio strider. You say that the item is necessary. The Plan denied 
your request. The Plan says the requested item is not primarily medical in nature. Therefore, coverage criteria 
has not been met. 
 
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 CS4 cardio strider (A9300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic CGM. 
 
You asked the Plan to pre-approve the therapeutic CGM. You say that you would like reconsideration because 
the CGM is medically necessary. The Plan denied your request. The Plan says the member is taking Metformin 
tablets twice a day and insulin as needed on a sliding scale. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the therapeutic CGM. Our reviewer 
says that there is insufficient data to determine if the member meets LCD coverage criteria. Our physician 
reviewer found the record does not show that the member is taking insulin multiple times oer day or checking 
their blood glucose at least 4 times per day. 
 
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 therapeutic CGM have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a therapeutic CGM.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on June 17, 2020. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that your last copayment was $46. You 
say that you want to know why the cost increased. The Plan denied your request. The Plan says the copayment 
applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $155 
copayment for each Medicare-covered radiological diagnostic service, not including x-rays performed in a 
physician's office or at a free-standing facility. Examples include, but are not limited to, specialized scans, CT, 
SPECT, PET, MRI, MRA, nuclear studies, ultrasounds, diagnostic mammograms and interventional 
radiological procedures.  
 
You have been asked to pay $128.75, which is less than the standard $155 copayment for the ultrasound. The 
ultrasound falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the ultrasound provided on June 17, 2020.