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

We decided that the Plan does not have to pre-approve the MiniMed 770G system insulin pump. 
 
You asked the Plan to pre-approve the pump. You say that this is medically necessary. The Plan denied your 
request. The Plan says this upgrade has not been shown to make a clinically significant difference. 
 
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 pump. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found no medical records have been submitted for review.  Therefore, there is no evidence to support that the 
requested device is currently 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 pump have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MiniMed 770G system insulin pump.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the pain is not mostly localized to the back. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 injections. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found you have chronic low back pain which is probably from the facet joint. You have had physical therapy. 
The EMG/NCV exam ruled radiculopathy and peripheral neuropathy. The physical exam supports facet-
mediated pain. The requested procedure is medically reasonable and necessary.  It meets the criteria of the 
LCD. 
 
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 injections have been met. Therefore, we decided that the Plan has to pre-
approve facet joint injections.  
 
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 Olmesartan Medoxomil. 
 
You asked the Plan to pre-approve Olmesartan Medoxomil. You say that this is the only medication that is 
working for the enrollee. The Plan denied your request. The Plan says this drug is not covered for the enrollee's 
condition under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Olmesartan Medoxomil.  
 
Benefits for Olmesartan Medoxomil 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve CT scan of the chest 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 that the enrollee will be eligible for another CT scan in 2021. 
 
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 medically reasonable and necessary. Our physician reviewer found in 2018, the enrollee was 
noted to have one lung nodule. In 2019, the enrollee was noted to have multiple lung nodules. While the 
appearance of these nodules was described as being overall stable, the quantity of nodules appears to be 
different. A repeat CT is now being requested to monitor the nodules in this enrollee, who has a history of 
heavy smoking. The documentation supports the requested ongoing surveillance of a changing number of 
nodules in a high-risk patient. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
CT scan of the chest for the enrollee.  
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 9, 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 procedure codes 80157, 80177, 80201, 80162, 80159 and 80173 are 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. 
 
We find that CPT codes 80157, 80177, 80201, 80162, 80159 and 80173 are not supported in the medical 
record. Specifically, there is no documentation of testing on blood sampling. 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 laboratory services rendered on March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for ophthalmic diagnostic imaging provided 
on November 19, 2019. 
 
You asked the Plan to waive the coinsurance for ophthalmic diagnostic imaging. You say that you were not 
informed of the additional charges beyond the office copayment. You state that you do not understand why 
diagnostic testing is necessary when you were already diagnosed. The Plan denied your request. The Plan says 
the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for diagnostic tests and procedures. 
 
You received ophthalmic diagnostic imaging on November 19, 2019. The total allowed amount is $1,255.45 
and 20% of that is $251.09.   
 
You have been asked to pay the total coinsurance amount of $251.09 for ophthalmic diagnostic imaging. 
Ophthalmic diagnostic imaging 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 coinsurance for ophthalmic diagnostic imaging 
provided on November 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the partial denture repair (D5621) 
provided from June 16, 2020. 
 
You asked the Plan to pay the in network rate for the partial denture repair. You say that you had a tooth break. 
You say that no dentists were available to see you. You say that your front tooth on your partial denture also 
broke. You say that you finally found a dentist that would see you. You say that the dentist that the plan 
representative gave you was too far away. You also say that the services you received should be covered cause 
there are no plan dentists in your area. The Plan denied your request. The Plan says partial denture repair is not 
listed as a covered service. 
 
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 partial denture repair is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate 
for the partial denture repair (D5621) provided from June 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 33340, CPT 93662) provided on May 4, 
2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Centers for Medicare & Medicaid Services 
(CMS) covers transcatheter mitral valve repair (TMVR) under Coverage with Evidence Development (CED) 
with the above conditions.  
 
We looked at the file and Medicare rules. This service is only covered when provided under Coverage with 
Evidence Development (CED). The submitted documentation does not contain clinical trial information. The 
list of approved trials is listed at https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-
Development/TMVR.html. These services are only covered when provided as part of an approved clinical trial. 
Additionally, CPT code 93662 is an add-on code and was billed with a primary code that is not eligible for 
payment. Therefore, the add-on code is also not eligible for payment. 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 pay for the services (CPT 33340, CPT 93662) provided on May 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a new patient podiatry visit (99203) on 
June 29, 2020. 
 
You asked the Plan to waive the copayment for a new patient podiatry visit. You say that you went in for 
routine foot care and were not told in advance you would have to pay the copayment amount.  The Plan denied 
your request. The Plan says the correct copayment was 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 each non-routine Medicare-covered foot care visit.  
 
You have been asked to pay a $40 copayment for a new patient podiatry visit. A new patient podiatry visit is 
not a routine service and falls within the "Podiatry services - Medicare-covered" 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 a new patient podiatry visit (99203) on June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, prophylaxis, and 
bitewings provided on August 5, 2020 by an OON provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation, prophylaxis, and bitewings. You say that you 
have a $300 dental benefit that covers services provided both in-network and out-of-network. The Plan denied 
your request. The Plan says these services were rendered by an OON provider. The Plan also says that this 
claim was processed correctly. 
 
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, you are responsible for the difference 
between the billed amount and allowed amount for services rendered OON. Therefore, we decided that the Plan 
does not have to pay for the comprehensive oral evaluation, prophylaxis, and bitewings provided on August 5, 
2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the digital hearing aid (V5257) rendered by the out of 
network (OON) provider on August 12, 2020. 
 
You asked the Plan to pay for the hearing aid. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the hearing aid was rendered by an out of 
network provider, without prior authorization. 
 
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. The Plan has network providers available 
who can provide the item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no 
exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to 
pay for the digital hearing aid (V5257) rendered by the out of network (OON) provider on August 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), 
periodontal maintenance (D4910), and gingival irrigation (D4921 x 4) provided on June 25, 2020. 
 
You asked the Plan to pay for the dental services. You say that you understood that the Plan covers preventive 
dental services as long as you go to an approved dentist. You say that you have received $0 for the preventive 
cleanings and periodontal treatments that you received this year. You say that the regular cleaning should be 
covered at least. You also say that this was covered under your previous provider. The Plan denied your 
request. The Plan says the services you received are not preventive cleaning services and therefore are not 
covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The record shows that you did not receive a preventive cleaning. 
Therefore, we decided that the Plan does not have to pay for the topical application of fluoride varnish 
(D1206), periodontal maintenance (D4910), and gingival irrigation (D4921 x 4) provided on June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and smoking cessation counseling (99214, 
99406) provided on July 16, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit and smoking cessation counseling. You say that the services 
provided were medically necessary. The Plan denied your request. The Plan says prior authorization was not 
obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit and smoking cessation counseling 
(99214, 99406) provided on July 16, 2020, by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interlaminar/interspinous process 
stabilization/distraction device. 
 
You asked the Plan to pre-approve the device. You say that this device would provide significant clinical and 
quality of life benefits. The Plan denied your request. The Plan says there is inconclusive or non-supportive 
evidence for this device. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the spacer 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an interlaminar/interspinous process stabilization/distraction device.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for BLS emergency ambulance (A0429) and ground mileage 
(A0425) provided May 15, 2019. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee did not provide insurance 
information until after timely filing limit had past. The enrollee was invoiced timely. The Plan denied your 
request. The Plan says the claim was submitted past the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ambulance services was not filed until 06/01/2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for BLS emergency ambulance (A0429) and ground mileage (A0425) provided 
May 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lower denture rebase (D5711) provided on August 3, 
2020. 
 
You asked the Plan to pay for the dental services. You say that the services were preapproved. You say that this 
should be covered. You also say that you need to cancel your insurance due to financial reasons. The Plan 
denied your request. The Plan says lower denture rebase is not listed as a covered service. 
 
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. Additionally, the record does not show that the Plan pre-approved this 
service. Therefore, we decided that the Plan does not have to pay for the lower denture rebase (D5711) 
provided on August 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the computerized dynamic posturography sensory 
organization test (CPT 92548) provided on May 27, 2020. 
 
You asked the Plan to pay for the services. 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee is a 70-year-old female with dizziness. There is minimal information provided regarding 
duration and nature of her symptoms. The enrollee's documented diagnoses include: viral disease exposure, 
cerebral atherosclerosis and dizziness. She underwent Computerized dynamic post-urography sensory 
organization test on May 27, 2020. Per the reviewed literature, Computerized dynamic posturography (CDP) 
testing, also called balance board testing or equilibrium platform testing (EPT), is unproven and not medically 
necessary for evaluating any condition, including but not limited to balance disorders due to insufficient 
evidence of efficacy. The requested computerized dynamic posturography sensory organization test (CDP-
SOT) is not 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the computerized dynamic posturography sensory organization test (CPT 92548) provided on 
May 27, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services provided on October 2, 2019, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the surgical services provided on October 2, 2019, 
by an out-of-network (OON) provider.