Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine home health skilled nursing visits. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have not had 
a recent decline in your functional status. You are medically stable and have not been recently hospitalized. 
You have no need for complex wound care, drug administration, or management of feeding tubes. The Plan has 
approved five skilled nursing visits. The records do not support that nine further skilled nursing visits are 
reasonable or medically necessary. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve nine home health skilled nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantable wireless pulmonary artery pressure 
sensor coded as C2624, 93264 and 33289. 
 
You asked the Plan to pre-approve the implantable wireless pulmonary artery pressure sensor. You say that the 
records provided should support the necessity of the requested service. The Plan denied your request. The Plan 
says this service is considered to be experimental and investigational and is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the implantable wireless pulmonary artery pressure sensor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the implantable wireless pulmonary artery pressure sensor 
coded as C2624, 93264 and 33289.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the extraction provided by an oral surgeon.
You asked the Plan to pre-approve the extraction. You say that the tooth broke off and is cutting your tongue
and causing sores. You say that the tooth needs to be extracted. The Plan denied your request. The Plan says
dental services are only covered when rendered by a participating general dentist.
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, services provided by a non-general
dentist are not among those covered under this benefit. Therefore, we decided that the Plan does not have to
pre-approve the extraction provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you are temporarily residing out of network 
but will be returning home in two months. You nearly slipped and fell after bathing and you need the chair so 
you do not have another accident The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on October 28, 2019.

You asked the Plan to pay for drug test. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the place of service. 

We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken in an office setting, therefore the Place of Service (POS) code 81 - indicating an independent laboratory setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.

You asked the Plan to the continued dialysis services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this provider is outside the medical group contract and the medical group has an alternative provider who can deliver the home dialysis care.

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 the medical services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary metal partial denture (D5213). 
 
You asked the Plan to pre-approve the maxillary metal partial denture. The Plan denied your request. The Plan 
says the documentation submitted demonstrates the remaining supporting teeth require significant restoration. 
The Plan also says that the Plan does not allow approval of partial dentures when more than 50% of the 
remaining teeth require significant restoration. 
 
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 maxillary 
metal partial denture 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 maxillary metal partial denture. Our 
reviewer says that a maxillary partial denture is not medically necessary. Our physician reviewer found 
coverage for a maxillary partial denture cannot be determined until the treatment of the remaining maxillary 
teeth is carried out and evaluated if sound abutments are present to support a partial denture. 
 
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 maxillary metal partial denture have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a maxillary metal partial denture (D5213).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on February 12, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z code identifier should be put in the 
comment/narrative field of the claim. Based on this information, we decided that Medicare rules for coverage 
of the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on February 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you are very weak and are unable to lift
yourself since you broke your ankle. You say that you need the requested equipment in order to maintain your
personal hygiene. You stated that you need to avoid any infection that might interfere with your chemotherapy
treatment. You say that you cannot afford to put your health on the line, and you asked the Plan to reconsider
providing coverage for the requested item. The Plan denied your request. The Plan says this item is not a
covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a cone beam CT capture and interpretation (D0365), mandibular
partial denture (D5214), and precision attachment (D6950).
You asked the Plan to pre-approve the cone beam CT capture and interpretation, mandibular partial denture,
and precision attachment. You say that you cannot have traditional dentures because they will not stay in your
mouth. The Plan denied your request. The Plan says that the cone beam CT capture and interpretation,
mandibular partial denture, and precision attachment do not meet the coverage criteria under your supplemental
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. The Plan covers the cone
beam CT capture and interpretation, mandibular partial denture, and precision attachment 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 cone beam CT capture and
interpretation, mandibular partial denture, and precision attachment. Our reviewer says that the criteria for
coverage have been met for coverage of a cone beam CT (D0365), mandibular removable partial denture
(D5214), and precision attachments (D6950). Our physician reviewer found the diagnostic capability of the
cone beam CT when extensive rehabilitation is needed is very useful to determine bone thickness where
implants are needed. Our reviewer found that precision attachments can achieve better retention and stability
where no distal abutment retainers are present as in this case. Our physician reviewer also found that a
mandibular partial denture would restore the enrollee's masticatory function.
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 cone beam CT capture and interpretation, mandibular partial denture, and
precision attachment have been met. Therefore, we decided that the Plan has to pre-approve a cone beam CT
capture and interpretation (D0365), mandibular partial denture (D5214), and precision attachment (D6950).
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the ophthalmology services (92014, 92133 and 92083). You say that you 
would like reconsideration because you have been seeing this provider since 2019. The Plan denied your 
request. The Plan says there are in-network providers available who may render this service. 
 
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 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on March 30, 2020. 
 
You asked the Plan to waive the copayment for an MRI. You say that you were not informed of the charges 
and cannot afford the copayment. 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 $295 
copayment for diagnostic radiology other than CT scans provided by a provider other than a primary care 
physician.  
 
You have been asked to pay a $295 copayment for an MRI. An MRI 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 MRI provided on March 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided on February 20, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services that you provided on February 20, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you are in severe pain and need these 
services. The Plan denied your request. The Plan says there are in-network providers available for these 
services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor sensor (HCPCS A9276), 
transmitter (HCPCS A9277), and 
 
You asked the Plan to pre-approve the supplies. You say that adding the Dexcom to the pump and using the 
Control IQ feature would allow the pump to adjust the enrollee's basal rates for him based on glucose levels. 
The Plan denied your request. The Plan says the requested continuous glucose monitoring supplies are not 
covered Medicare items. 
 
The Plan must follow Medicare rules. Medicare rules say that continuous glucose monitors are covered when 
they are considered therapeutic and meet the medically necessary criteria from Medicare.  
 
The supplies being requested for a Dexcom monitor are considered non-therapeutic. Based on this information, 
we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a continuous glucose monitor sensor (HCPCS A9276), transmitter (HCPCS 
A9277), and
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CTC assay provided on January 12, 2018. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that CTC testing is not medically necessary.  
 
We looked at the file and Medicare rules. Per the applicable LCD, the requested CTC assay is not medically 
reasonable and necessary, and therefore is non-covered. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the CTC assay provided on January 12, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on
January 9, 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 80307 and G0482 are not supported in the medical record. Specifically, the
documentation does not support any evidence of an established relationship between the enrollee and the
ordering physician. 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 80307
and G0482 provided on January 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic screening testing provided on December 20, 2019. 
 
You asked the Plan to pay for genetic tests. You say that you are appealing with medical records. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because these tests are 
not covered for the diagnoses listed and were performed for screening purposes. 
 
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 tests at issue in this appeal, genetic tests, were requested solely for screening purposes. Medicare does not 
cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
genetic screening testing provided on December 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar decompression for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your
request. The Plan says it is not clear from the records which level of the lumbar spine the surgery is being
requested for.
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 surgery. Our reviewer says that the
requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer
found the imaging studies do not show evidence of severe nerve compression that correlates with physical
exam findings. The surgery is not needed.
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 surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve a lumbar decompression for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left leg prosthesis. 
 
You asked the Plan to pre-approve the prosthesis. You say that your current prosthesis has never fit properly 
and rotates. You want to go to a new provider because you no longer trust the provider that you received your 
current prosthesis from. The Plan denied your request. The Plan says a left leg prosthesis is not covered benefit 
at this time. The benefit for a left leg prosthesis will renew on 6/03/2024. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have left leg prosthesis. left leg prosthesis serves the same purpose as the prosthesis. 
Therefore, we decided that the Plan does not have to pre-approve left leg prosthesis.