Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker with a seat attachment for the enrollee. 
 
You asked the Plan to pre-approve the walker. You say that the enrollee has a neuromuscular disorder that 
impairs ambulation, and makes the enrollee prone to falls/injuries. The Plan denied your request. The Plan says 
a standard walker can be covered. 
 
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 walker. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the medical records provided there is no documentation that the enrollee has a severe 
neurologic disorder/other condition causing restricted use of one hand that would make her unable to use a 
standard walker. 
 
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 walker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a walker with a seat attachment for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hereditary pancreatic cancer and melanoma panel 
testing. 
 
You asked the Plan to pre-approve the requested testing. You say that the testing will help estimate the 
enrollee's risk to develop other cancers in the future. The Plan denied your request. The Plan says the results 
will not directly impact therapeutic decision making, treatment plan, or clinical management. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
In this case, there are insufficient records showing that the results of the testing will be used to determine a 
specific diagnosis or treatment strategy. The testing at issue in this appeal is being requested for screening 
purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does 
not have to pre-approve a hereditary pancreatic cancer and melanoma panel testing.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services rendered. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 95999 is not supported. 
 
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 95999 is unlisted neurological or neuromuscular 
diagnostic procedure. 
 
We find that CPT code 95999 is not supported in the medical record. Specifically, the records show that Train 
of Four testing was performed and there is a more appropriate code for these services. 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 pay for the testing services rendered.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-
network provider. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says that 
the Plan has pain management providers in-network that can provide 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extractions (D7210 x 2) provided on July 23, 
2020. 
 
You asked the Plan to pay for the dental service. You say that the provider in this case is out of network. You 
say that you have $816 remaining on your dental allowance. You also say that extractions provided out of 
network have a cost share of 45%. The Plan denied your request. The Plan says the provider in this case has 
opted out of Medicare. The Plan also says that payment cannot be made to providers who have opted out of 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
surgical extractions (D7210 x 2) provided on July 23, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 units of test evaluation/neurobehavioral status exam 
(96133) and 7 units of test administration and scoring (96139). 
 
You asked the Plan to pre-approve 3 units of test evaluation/neurobehavioral status exam and 7 units of test 
administration and scoring. You say that these services are medically necessary. The Plan denied your request. 
The Plan says the additional testing is not medically 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 3 units of test 
evaluation/neurobehavioral status exam and 7 units of test administration and scoring. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this patient does not meet the criteria for the needed extra 3 units and 7 units of evaluation 
and management as this patient already has been approved for 5 units of 60 minute evaluation and 5 units of 30 
minutes evaluation for assessment and interpretation of the testing. Therefore, the additional requests for 3 and 
7 units do not appear 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 3 units of test evaluation/neurobehavioral status exam and 7 units of test 
administration and scoring have not been met. Therefore, we decided that the Plan does not have to pre-
approve 3 units of test evaluation/neurobehavioral status exam (96133) and 7 units of test administration and 
scoring (96139).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the enrollee does not meet step therapy requirements. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
request for Prolia does not appear medically reasonable or necessary. Our physician reviewer found the 
enrollee is an 88-year-old female with osteoporosis. The Plan requires a trial of Zoledronic Acid before they 
will approve the requested drug. In this case, the patient has not tried and failed the required drug. There is no 
documentation provided indicating that the Plan?s required drug would likely be less effective and/or likely 
have adverse effects 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical removal of erupted tooth. 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this 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 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 
surgical removal of erupted tooth.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically 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 monitor. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found you are noted to have type 2 diabetes, for which you take oral medication and a set dose of mixed 
insulin. How often you are testing your blood glucose is not documented. There is no evidence that you use the 
results of blood glucose testing to self-adjust insulin doses multiple times per day. As such, this monitor is not 
shown to be medically necessary or reasonable. 
 
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron Depot four-month kit. 
 
You asked the Plan to pre-approve Lupron Depot (J9217). You say that you want the enrollee treated with this 
drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Lupron Depot four-month kit.  
 
Benefits for Lupron Depot (J9217) 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental casts (D0470) provided December 13, 2019. 
 
You asked the Plan to pay for the dental casts. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this item is not a covered item under your dental 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. Therefore, we decided that the Plan does not have to pay for dental 
casts (D0470) provided December 13, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital care provided on July 18, 2020, through July 20, 2020. 
 
You asked the Plan to pay for inpatient hospital care. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that services could have been provided at an observational level of care. 
 
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 record indicates that the Plan received medical records from the non-
contracted provider in this case. We asked the Plan to send us additional information on your case. However, 
the Plan failed to forward the information in a timely manner. This means we did not have sufficient 
information to make a decision on medical necessity. Therefore, we decided that the Plan has to pay for 
inpatient hospital care provided on July 18, 2020, through July 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic resonance (eg, proton) imaging (MRI), brain 
(including brain stem); without contrast material (70551). 
 
You asked the Plan to pre-approve an MRI brain. You say that the enrollee needs an MRI. The Plan denied 
your request. The Plan says there is insufficient clinical information to approve the requested study. 
 
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 brain. Our reviewer says that 
the MRI is not medically necessary. Our physician reviewer found records do not provide sufficient 
documentation for study. 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 an MRI brain. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Magnetic resonance (eg, proton) imaging (MRI), brain (including brain stem); without 
contrast material (70551).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve these services. You say that you need the scooter for use outside of the 
home. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion for a physician's consultation to be 
provided by the out-of-network provider. 
 
You asked the Plan to pre-approve the second opinion for a physician's consultation. The Plan denied your 
request. The Plan says that the Plan authorizes use of out-of-network providers when you need urgent or 
emergent care, or the needed care is not available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a second 
opinion for a physician's consultation to be provided by the out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on May 27, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT codes 28289-RT and 28289-59-LT is 1. You billed 2 units of each code, 
exceeding the MUE. 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 pay for the surgical services rendered 
on May 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213). 
 
You asked the Plan to pre-approve the dental item. You say that the enrollee has a broken upper metal clasp 
that is not repairable. You also say that the enrollee can no longer wear his upper partial. The Plan denied your 
request. The Plan says one of (D5110, D5130, D5211, D5213), once per sixty months. 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 one upper 
complete or partial denture per sixty months has been reached. The record shows that the Plan previously paid 
for a partial upper denture that you received on February 6, 2018. Therefore, we decided that the Plan does not 
have to pre-approve a partial upper denture (D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6534. 
 
You asked the Plan to pre-approve the compression stockings. You say that the compression stockings are 
medically necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6534 are 
non-covered 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 A6534.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transfer bench. 
 
You asked the Plan to pre-approve transfer bench. You say that the item is needed to bathe safely in your 
home. The Plan denied your request. The Plan says this is considered an item of comfort or convenience. 
 
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 transfer bench.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and core build up (D2950) for tooth # 
28. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to have a portion of this 
procedure to be covered by the plan. The Plan denied your request. The Plan says crowns are not listed as a 
covered service. The Plan says that core build up is not listed as a covered service either. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
crown (D2740) and core build up (D2950) for tooth # 28.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Positron Emission Tomography Computed 
Tomography (PET/CT) scan of the head to thigh. 
 
You asked the Plan to pre-approve PET/CT scan. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because routine 
testing modalities should be employed before PET scan if clinical decisions to be made are likely to be 
answered by these. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET/CT scan. Our reviewer says that 
the enrollee does not meet the Medicare criteria for the requested scan. Our physician reviewer found 
guidelines recommend surveillance with CT scan every 6 months for the first 2 years or as clinically indicated. 
PET scan for surveillance is not recommended due to the high rate of false positives. Therefore, this service is 
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 PET/CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Positron Emission Tomography Computed Tomography (PET/CT) scan of the head to thigh.