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

We decided that the Plan does not have to pay for a CPAP device and supplies received on January 29, 2020. 
 
You asked the Plan to pay for the supplies. You say that this should be paid for. The Plan denied your request. 
The Plan says the services exceeded the maximum allowance that would be clinically appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment can have maximum 
utilization amounts attached to them.  
 
A7034 and A7037 are only covered once every three months. These same items were last received on 
December 17, 2019, which is less than three months from the date of service of January 29, 2020. 
 
A7035 is only covered once every six months. This same item was last received on December 17, 2019, which 
less than six months from the date of service on January 29, 2020.  
 
A7038 has been paid to the maximum units allowed on this same claim, so the additional units cannot be also 
paid. 
 
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 pay for a CPAP device and supplies received on January 
29, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility services beyond October 26, 
2020. 
 
You asked the Plan to pre-approve SNF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the continued services are not medically necessary. 
 
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 SNF care. Our reviewer says that the 
continued services are medically necessary. Our physician reviewer found the submitted records show that you 
were admitted to the SNF on September 25, 2020 after hospitalization for a stroke. The limited records do not 
show that you need daily skilled nursing services. The records show that you do require skilled therapy on a 
daily basis. As a practical matter, you require the necessary services on an inpatient basis at the SNF level of 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve continued 
skilled nursing facility services beyond October 26, 2020.  
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided out network on June 9, 2020.  
 
You asked the Plan to pay for out of network hearing services and hearing aids. You say that these hearing aids 
should be covered by the Plan. The Plan denied your request. The Plan says you were told this provider was not 
in network prior to the purchase. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from a network provider with prior authorization. You were aware this 
provider was not in network prior to the purchase. Therefore, we decided that the Plan does not have to pay for 
hearing aids provided out network on June 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to molecular pathology services for the 
enrollee with an out-of-network provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee is limited to specialists, ancillary providers, and hospitals available within 
the PCP's IPA or medical group. 
 
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 molecular pathology services for the enrollee with an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share applied to the enrollee's deductible for services 
provided on February 25, 2020. 
 
You asked the Plan to waive this cost share. You say that the enrollee should only be charged a $5 copayment. 
The Plan denied your request. The Plan says the records show the rendering provider did not become a 
participating provider until March 6, 2020. The Plan states that this provider was out of network as of February 
25, 2020 and therefore application of the deductible was applied correctly.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $1500 deductible for 2020. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is $1500 for deductible. This cost sharing is a contractual obligation 
that had not been met at the time these services were received on February 25, 2020. Therefore, we decided 
that the Plan does not have to waive the cost share applied to the enrollee's deductible for services provided on 
February 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the INTRACEPT 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 there is little evidence in the medical literature to suggest that this is an appropriate 
procedure for back pain. 
 
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 procedure is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Intracept procedure 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the INTRACEPT procedure for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transforaminal epidural injections with imaging 
guidance. 
 
You asked the Plan to pre-approve transforaminal epidural injections with imaging guidance. You say that the 
injections are medically necessary. The Plan denied your request. The Plan says while they partially approve 
the treatment they can only approve 1 level bilaterally or 2 levels unilaterally because the request exceeds the 
guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The request is for injections bilateral at 2 levels. Based on this 
information, we decided that Medicare rules for coverage of transforaminal epidural injections with imaging 
guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve transforaminal 
epidural injections with imaging guidance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the allergy injection rendered on June 22, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file and Medicare rules. The file shows that you received an allergy injection from an out-of-
area provider. The services were not for an unforeseen illness or injury. 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 allergy injection rendered on June 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor (CGM) 
and supplies. 
 
You asked the Plan to pre-approve a FreeStyle Libre CGM and supplies. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the 
requested CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that CGMs are only covered when your insulin 
treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results. 

We looked at the file and Medicare rules. Review of the file does not support that you frequently adjust your 
insulin medication. Based on this information, we decided that Medicare rules for coverage of a FreeStyle 
Libre CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
FreeStyle Libre continuous glucose monitor (CGM) and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 11, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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. This provider is not a network provider. We have also determined that these services 
are not urgent or emergent, nor were they approved in advance. 
 
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 provided on June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5214) and a partial lower 
denture (D5213). 
 
You asked the Plan to pre-approve the dental items. You say that the previous partial dentures that you received 
were poorly made. You say that the provider that made them was unethical. You say that you should be able to 
get new dentures from a new dentist that is more experienced. You say that he has already done more to help 
you than any other dentist. The Plan denied your request. The Plan says 1 partial denture, per arch, every 5 plan 
years is covered. The Plan says that you received partial dentures on July 28, 2017 and January 22, 2018 that 
were paid. The Plan also says that the frequency limit has been reached. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 1 denture, per 
arch, every 5 plan years has been exceeded. Therefore, we decided that the Plan does not have to pre-approve a 
partial upper denture (D5214) and a partial lower denture (D5213).  
 
Your complaint about your previous dental provider being unethical is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar sacral facet joint radiofrequency neurolysis 
(64635). 
 
You asked the Plan to pre-approve lumbar sacral facet joint radiofrequency neurolysis. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that thermal radiofrequency destruction of cervical, 
thoracic or lumbar paravertebral facet joint (median branch) nerves will be considered to be medically 
reasonable and necessary when specific criteria is met. 
 
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 lumbar sacral facet joint radiofrequency 
neurolysis. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
coverage criteria is 80% pain relief from each set of diagnostic medial branch block (MBBs). This was not 
achieved and the tests should be interpreted as negative. The requested procedure is not medically reasonable 
or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar sacral facet joint radiofrequency neurolysis have not been met. 
Therefore, we decided that the Plan does not have to pre-approve lumbar sacral facet joint radiofrequency 
neurolysis (64635).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve CPT Code 64636 and CPT Code 64635. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says that the services are not 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 services. Our physician reviewer 
found the documentation supports that the coverage criteria have been met in this case. The enrollee has not 
reached the maximum number of facet joint injection sessions which is five (5) per year in the lumbar spine. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve CPT Code 64636 and CPT Code 64635.  
 
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 imaging services (73521) provided to the enrollee on June 
11, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says it was determined the billed service, 73521, was denied because two or more diagnosis 
codes associated to it are mismatched. The Plan says that according to the ICD-10-CM Official Guidelines for 
Coding and Reporting, some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on 
the left, right or is bilateral. It is not appropriate to report unspecified, or left and right diagnosis codes when a 
more specific (e.g. bilateral) code is available; therefore, the reported service has been denied.  
 
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 claim submitted cannot be paid 
as billed due to an error with the codes used. Medicare rules for coverage of this service have not been met. 
Therefore, we decided that the Plan does not have to pay for imaging services (73521) provided to the enrollee 
on June 11, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says it is feasible to meet the enrollee's needs at a lower level of care, such as long term 
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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found no required skilled nursing services are 
identified. Skilled therapy services are not needed on a daily basis. The enrollee does not require the necessary 
services, as a practical matter, on an inpatient basis in the 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses you received on February 26, 2020. 
 
You asked the Plan to pay for the eyeglasses. You say that you should be reimbursed. The Plan denied your 
request. The Plan says you did not submit a receipt. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you submit a receipt for proof of payment. 
 
We looked at the file and the Plan's rules. The records show that you have not submitted a receipt for proof of 
payment of the requested eyeglasses. Based on this information, we decided that the Plan's rules for coverage 
 
 
of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the 
eyeglasses you received on February 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a combination sit to stand system with a seat life feature 
coded as E0637. 
 
You asked the Plan to pre-approve the requested sit to stand system. You say that you believe that this is 
medically necessary because you cannot perform transfers on your own. The Plan denied your request. The 
Plan says the requested item is specifically listed as noncovered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the DME contractor provides a list of codes 
which are considered noncovered.  
 
The requested item is listed as noncovered. Although the use of this device may be appropriate, it is not an item 
which can be covered by Medicare or your Plan. Therefore, we decided that the Plan does not have to pre-
approve a combination sit to stand system with a seat life feature coded as E0637.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repair of brow ptosis (supraciliary, mid-forehead or 
coronal approach) (CPT Code 67900). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because the Plan's records show that this service 
has already been approved, performed, billed and paid in August 2019. 
 
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 services. Our physician reviewer 
found the Repair of Brow Ptosis and Blepharoptosis are considered medically necessary for the following 
functional indications: Clinical notes, rather than formal visual field testing, support a decrease in peripheral 
vision and/or upper field vision, from eyebrow ptosis; or Brow malposition that would prevent adequate 
correction of dermatochalasis, blepharochalasis or blepharoptosis; and Photographs document obvious 
dermatochalasis, ptosis, or brow ptosis. In this case, the file does not contain photographs documenting obvious 
dermatochalasis, ptosis, or brow ptosis. 
 
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 pre-approve repair of brow ptosis (supraciliary, mid-forehead or coronal approach) (CPT Code 67900).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion interspinous spacer for the enrollee. 
 
You asked the Plan to pre-approve the spacer. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates 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 the spacer. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the spacer remains 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 spacer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Superion interspinous spacer for the enrollee.