Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 10, 2019. 
 
You asked the Plan to pay for the laboratory 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. 
 
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 laboratory services at issue in this appeal were requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on October 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture. 
 
You asked the Plan to pre-approve the denture. You say that your current prosthesis is broken. The Plan denied 
your request. The Plan says this is not covered once the benefit has been 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, the requested items or services are not 
among those covered under this benefit, as dentures were received within the past five years. Therefore, we 
decided that the Plan does not have to pre-approve a maxillary partial denture.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positron emission tomography (PET) services.

You asked the Plan to pre-approve the PET scan. You say that your neurologist has stated that you have progressive dementia and that there are some motor features. You say that your doctor believes there is another possibility that you could have a motor variant Fronto temporal dementia and that the PET scan could be helpful at differentiating this from other forms of dementia. You say that you have had a recent diagnosis of prostate cancer and that your provider is also investigating lung nodules that were detected. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of the requested PET scan.

The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is considered reasonable and necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both AD and FTD. 

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 PET scan. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a history of progressive dementia. Our physician reviewer found that the medical records provided for review did not support that the enrollee met the diagnostic criteria for both FTD and AD. The records provided for review did not show that the provider suspected both AD and FTD.

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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve positron emission tomography (PET) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network cardiologist. 
 
You asked the Plan to pre-approve these services. You say that you have blood pressure problems. The Plan 
denied your request. The Plan says the services are available from network providers. 
 
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 
a referral to an out-of-network cardiologist.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography scan (LDCT) for lung 
cancer screening 
 
You asked the Plan to pre-approve a LDCT for lung cancer screening. You say that you need this because you 
were previously a heavy smoker. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of Medicare coverage of lung 
cancer screening with LDCT, beneficiaries must have a tobacco smoking history of at least 30 pack-years. 
 
We looked at the file and Medicare rules. The submitted medical records indicate that you have a 25 pack-year 
smoking history. Based on this information, we decided that Medicare rules for coverage of a LDCT for lung 
cancer screening have not been met. Therefore, we decided that the Plan does not have to pre-approve a low 
dose computed tomography scan (LDCT) for lung cancer screening
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tradjenta tablets. 
 
You asked the Plan to pre-approve Tradjenta tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Tradjenta tablets are not covered by the enrollee's 
Medicare Part B benefit. 
 
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 Tradjenta tablets.  
 
Benefits for Tradjenta tablets 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion Interspinous device surgery. 
 
You asked the Plan to pre-approve Insertion of Interlaminar/Interspinous Process Stabilization/Distraction 
Device (22869) and  Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22870). 
You say that the enrollee needs this procedure for pain relief. The Plan denied your request. The Plan says the 
Vertiflex Superion interspinous spacer procedure is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Insertion of Interlaminar/Interspinous 
Process Stabilization/Distraction Device (22869) and Insertion of Interlaminar/Interspinous Process 
Stabilization/Distraction Device (22870). Our reviewer says that the requested items/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 Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device 
(22869) and  Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22870) have not 
been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion Interspinous 
device surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - complete services of radiographic images 
including bitewing x-rays (D0210) received on September 1, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says benefits for this service have been satisfied, and the frequency limitation has been satisfied. 
 
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 D0210 once 
per year. 
 
The file shows that this service was already received and paid for on June 10, 2020. Based on this information, 
we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the 
Plan does not have to pay for intraoral - complete services of radiographic images including bitewing x-rays 
(D0210) received on September 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cardiomems System for the enrollee. 
 
You asked the Plan to pre-approve a Cardiomems System. You say that this system is medically necessary for 
the enrollee. The Plan denied your request. The Plan says that this service is considered experimental and 
investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Cardiomems System. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. In 
this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in 
only one randomized prospective trial to help reduce hospital readmission compared to standard medical 
therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. 
Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and 
not recommended in current guidelines for the treatment of heart failure. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for a Cardiomems System. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Cardiomems System have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Cardiomems System for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional continuous glucose monitor supplies (K0553). 
 
You asked the Plan to pre-approve the continuous glucose monitor supplies. You say that you would like 
reconsideration because these supplies are medically necessary. The Plan denied your request. The Plan says 
three units of supplies are considered not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that only one (1) UOS of code K0553 may be billed 
to the DME MACs at a time. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the continuous glucose monitor supplies have not been met. Specifically, the record indicates that 
you are requesting 3 units of the continuous glucose monitor supplies, but only one may be billed at a time. 
Therefore, we decided that the Plan does not have to pre-approve additional continuous glucose monitor 
supplies (K0553).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on August 21, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you feel that you should not owe a 
copayment because the provider recommended it. 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 a $45 
copayment for each X-ray.  
 
You have been asked to pay a $45 copayment for an ultrasound. An 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 an ultrasound provided on August 21, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit provided on June 7, 2019. 
 
You asked the Plan to pay for the emergency department visit. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the claim was submitted untimely. 
 
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 emergency department visit was not filed until June 10, 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 the emergency department visit provided on June 7, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endoscopy service provided on July 31, 2019. 
 
You asked the Plan to pay for the endoscopy service. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says the claim was untimely. 
 
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 endoscopy service was not filed until August 3, 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 the endoscopy service provided on July 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 and 80307 provided on 
January 24, 2020. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 G0483 and 80307 are not supported in the medical record. Specifically, the 
documentation does not include medical records to support the clinical utility of the testing. Based on this 
information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the drug testing coded G0483 and 80307 provided on January 24, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy services. 
 
You asked the Plan to pre-approve the physical therapy services. You say that you would like reconsideration 
because the physical therapy is medically necessary. The Plan denied your request. The Plan says the records 
do not show physical therapy is medically necessary or that there has been a physical therapy evaluation. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy services. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found it  does not appear that you require the unique skills 
of a professional therapist to safely and effectively provide treatment, or that the services can be safely and 
effectively performed only by a therapist, or under the supervision of a therapist. 
 
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 physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional physical therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the post removal (D2955). 
 
You asked the Plan to pre-approve the post removal. You say that these services are medically necessary. The 
Plan denied your request. The Plan says these services are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
post removal (D2955).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care services provided on August 17, 2019. 
 
You asked the Plan to pay for the initial hospital care services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the claim was submitted untimely. 
 
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 initial hospital care services was not filed until November 3, 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 the initial hospital care services provided on 
August 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem-focused limited oral exam and periapical x-rays 
rendered on August 5, 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 exceeded the benefit limit. 
 
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 one exam 
every two years and periapical x-rays once every calendar year. 
 
We looked at the file and the Plan's rules. The file shows that you previously had a problem-focused limited 
oral exam and periapical x-ray on July 28, 2020 for which the Plan approved and paid. The services on August 
5, 2020 exceeded the Plan's benefit limit for these services. Therefore, we decided that the Plan does not have 
to pay for the problem-focused limited oral exam and periapical x-rays rendered on August 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LINX procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says neither Medicare or the plan covers this procedure. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found whereas the enrollee has documented gastroesophageal reflux, she has longstanding dysphagia 
and manometric evidence of incomplete bolus clearance. The possibility of diabetic gastroparesis and 
associated gut neuropathy has not been excluded as contributory to her GERD symptoms. Her LES is normal in 
structure and function, and does not require surgical augmentation. The documentation of both a hiatal hernia 
of approximately 3 cm in size and Schatzki's ring are relative contraindications to anti-reflux surgery in the 
enrollee's setting. As a whole, the medical necessity of the LINX procedure for the enrollee is not demonstrated 
by available records. While further motillity assessment is warranted, at this juncture weight reduction, lifestyle 
modification, and optimized acid suppression therapy may provide benefit to her GERD symptoms without the 
risks to the enrollee of proposed intervention. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the LINX procedure for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard for the enrollee. 
 
You asked the Plan to pre-approve the mouth guard. 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. 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 an occlusal guard for the enrollee.