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

 
We decided that the Plan does not have to pre-approve a home ventilator for the enrollee. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records do not show low oxygen levels in the blood at night. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has COPD and was recently hospitalized with an exacerbation. The arterial blood 
gas done during the hospitalization shows pCO2 elevation but is most consistent with acute hypoventilatory 
respiratory failure, rather than chronic. There is no ABG done during a stable state. Medicare does not cover a 
home ventilator when used as a BiPAP device. The AVAPS-AE mode of support can be provided with certain 
BiPAP devices. There is no evidence of BiPAP failure; the enrollee was successfully treated with BiPAP in the 
hospital. A home ventilator is not 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 the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 14 day system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says the submitted medical records do not document insulin dependence or self-testing at 
least four times a day. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the submitted documentation notes the enrollee is instructed to check blood sugar once daily. The 
enrollee does not use insulin. The requirements as outlined by the LCD are not met, medical necessity cannot 
be determined. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Freestyle Libre 14 day system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Omalizumab injections provided on 
January 24, 2020 and February 21, 2020. 
 
You asked the Plan to waive the coinsurance for the Omalizumab injections. You say that you were told the 
injections would be covered by insurance and you would only have to pay for the specialist's visit. The Plan 
denied your request. The Plan says the claims were reprocessed and you have been charged the correct cost 
sharing 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 Medicare-covered Part B chemotherapy drugs and other Part B drugs.  
 
You have been asked to pay $448.28 which is 20% of the allowed amount for the Omalizumab injections on 
each date of service. The allowed amount is $2,241.42. ($2,241.42 x 20% = $448.28). ($448.28 + $448.28 = 
$896.56). The Omalizumab injections fall within the ?Medicare Part B prescription drugs? 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 the Omalizumab injections provided on January 24, 2020 
and February 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the first 15 minutes of deep sedation/general anesthesia 
and each subsequent 15 minute increment of deep sedation/general anesthesia. 
 
You asked the Plan to pre-approve the deep sedation/general anesthesia services. 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 
first 15 minutes of deep sedation/general anesthesia and each subsequent 15 minute increment of deep 
sedation/general anesthesia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy services provided from October 22, 
2019 to December 3, 2019. 
 
You asked the Plan to pay for home infusion therapy services. You say that this enrollee has out-of-network 
benefits, so this claim should be processed manually for payment. The Plan denied your request. The Plan says 
the denial of payment for these services is correct, because the procedure code billed is not payable by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code S9328 is not valid for Medicare 
purposes and is not payable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home infusion therapy services have not been met. Therefore, we decided that the Plan does not 
have to pay for home infusion therapy services provided from October 22, 2019 to December 3, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that it was the ambulance staff's decision not to 
transport you to the hospital. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 28, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that foot orthotics are medically necessary. The Plan 
denied your request. The Plan says you do not meet criteria for coverage of these items. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a surgical endoscopy (CPT 31295) provided to the enrollee 
on September 20, 2019. 
 
You asked the Plan to pay for the endoscopy. You say that this should be paid for. The Plan denied your 
request. The Plan says procedure code 31295-50 is not supported by the medical records submitted. 
 
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 31295 is "surgical nasal/sinus endoscopy, with dilation 
(balloon dilation) of the maxillary sinus ostium, transnasal or via canine fossa." 
 
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 endoscopy. Our reviewer says that the 
services at issue in this case were not supported by the medical records submitted. Our physician reviewer 
found the documentation in the operative report documents balloon dilation of sphenoid sinus ostium. 
Documentation is not appropriate for CPT 31295. 
 
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 endoscopy have not been met. Therefore, we decided that the Plan does not 
have to pay for a surgical endoscopy (CPT 31295) provided to the enrollee on September 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CT Scans of the lumbar and thoracic spine (72128 and 
72131) provided on April 25, 2020. 
 
You asked the Plan to pay for the CT Scans. You say that you would like reconsideration because this claim 
was denied as a duplicate without payment on the original claim. The Plan denied your request. The Plan says 
these codes are duplicates of two that have been approved. 
 
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 72128 and 732131 are  not supported in the record. Specifically, the record supports 
that a single CT Scan of the thoracic spine and a single CT Scan of the lumbar spine were performed. Based on 
this information, we decided that Medicare rules for coverage of the CT Scans have not been met. Therefore, 
we decided that the Plan does not have to pay for CT Scans of the lumbar and thoracic spine (72128 and 
72131) provided on April 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided 
on March 8, 2020. 
 
You asked the Plan to pay for the CGP testing. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the CGP testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the Comprehensive Genomic Profile (CGP) testing provided on March 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Donepezil. 
 
You asked the Plan to pre-approve the Donepezil. You say that you would like to appeal this drug to treat the 
enrollee's conditions. The Plan denied your request. The Plan says this drug is not covered for the enrollee's 
condition by 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 Donepezil.  
 
Benefits for the Donepezil 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 pre-approve the surgical extractions (D7210) for tooth #'s 21, 22, 27 
and 28. 
 
You asked the Plan to pre-approve the surgical extractions (D7210) for tooth #'s 21, 22, 27 and 28. You say 
that your teeth hurt and it's hard to eat. You say that you need these teeth removed. The Plan denied your 
request. The Plan says the documentation submitted does not support the code requested. 
 
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. The Plan covers the surgical 
extractions (D7210) for tooth #'s 21, 22, 27 and 28 when the services are medically necessary and reasonable.  
 
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 surgical extractions (D7210) for 
tooth #'s 21, 22, 27 and 28. Our reviewer says that the criteria for coverage has not been met. Our physician 
reviewer found the documentation does not support the medical necessity for the surgical extractions (D7210). 
Our reviewer also found that though D2710 is not medically necessary, extraction code D7140 would suffice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the surgical extractions (D7210) for tooth #'s 21, 22, 27 and 28 have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the surgical extractions (D7210) for 
tooth #'s 21, 22, 27 and 28.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your 
request. The Plan says that you must have tried and failed both oral and intravenous bisphosphonates or have a 
medical reason why you cannot take them. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary. There is no history of intolerance to an IV bisphosphonate. The 
documentation does not support that Prolia is safe and effective for you. Our physician reviewer found that 
your condition does not meet criteria for coverage of Prolia. 
 
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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc (J7325). 
 
You asked the Plan to pre-approve the Synvisc. The Plan denied your request. The Plan says the information 
submitted does not meet the Plan's medical necessity guidelines for coverage. 
 
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 the Synvisc. Our reviewer says that 
Synvisc does not meet the Plan's coverage criteria. Our physician reviewer found the enrollee is noted to have 
bilateral knee osteoarthritis. A request has been made for Synvisc, a hyaluronic acid injection, to treat the 
osteoarthritis. The health plan requires that other forms of hyaluronic acid injections be used. Our reviewer 
found that there is no evidence that the enrollee is allergic to or intolerant of these other forms of hyaluronic 
acid. There is no evidence that the enrollee has tried and not responded to these other forms of hyaluronic acid 
injections. There is no documentation as to why these other forms of hyaluronic acid would not be expected to 
be safe and effective for the enrollee. Our physician reviewer also found that the requested Synvisc is not 
shown to be currently medically necessary and 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 Synvisc have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc (J7325).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair accessory, power seat elevation system, any 
type (E2300), for the enrollee. 
 
You asked the Plan to pre-approve the item. You say that the item is medically necessary. The Plan denied your 
request. The Plan says the item is not medically necessary. 
 
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 wheelchair accessory, power seat elevation system, any type 
(E2300), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services provided to the enrollee on March 3, 
2020. 
 
You asked the Plan to pay for the immunization. You say that this was denied in error. The Plan denied your 
request. The Plan says this was received as a preventive measure. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunization. 
Therefore, we decided that the Plan does not have to pay for immunization services provided to the enrollee on 
March 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation and bitewings x-rays provided on 
March 5, 2020. 
 
You asked the Plan to pay for the limited oral evaluation and bitewings x-rays. You say that an in-network 
provider gave a large estimate for services. You say that you should be able to see a dentist you are familiar 
with and trust. The Plan denied your request. The Plan says out-of-network dental services are not covered 
benefits. 
 
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, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation and bitewings x-rays provided on March 5, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve the SNF services. You say that you were admitted to the hospital because 
you broke your right ankle. You say that you are a very active person but currently you cannot walk or perform 
normal exercises. You say that you need SNF treatment and therapy to get stronger so you can go home safely 
and comfortably afterwards. The Plan denied your request. The Plan says you do not meet Medicare criteria for 
SNF care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF services. Our reviewer says 
that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing 
perspective, you received oral and inhaled medications and insulin. You had stable vital signs and you were 
treated for pain with effect. Regarding rehabilitation services, you received physical therapy (PT) and 
occupational therapy (OT) in the acute hospital. You were at a contact guard to minimal assist level with 
functional mobility including gait to a few steps. You could self-propel your wheelchair 150 feet with 
supervision. You required varying assist with activities of daily living. You remained non-weight-bearing to 
your right lower extremity for 6 weeks. There are no identifiable skilled nursing services. Although there are 
identifiable skilled therapy service needs, it is not medically necessary and reasonable to provide these skilled 
nursing or skilled therapy services on a "daily basis." You do not meet severity of illness or intensity of service 
criteria for an inpatient basis in a skilled nursing facility setting. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve SNF services.