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

We decided that the Plan does not have to pre-approve a low dose CT (LDCT) scan for lung cancer screening. 
 
You asked the Plan to pre-approve an LDCT scan. The Plan denied your request. The Plan says the coverage 
criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that an LDCT scan is covered when the above criteria 
are met. 
 
We looked at the file and Medicare rules. The records show that the enrollee quit smoking 24 years ago. The 
LCD criteria indicates that the enrollee must be a current smoker or one who has quit smoking within the last 
15 years. Based on this information, we decided that Medicare rules for coverage of an LDCT scan have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a low dose CT (LDCT) scan for 
lung cancer screening.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home health aide for custodial care. 
 
You asked the Plan to pre-approve a home health aide for custodial care. You say that you need the help of an 
in-home health aide. The Plan denied your request. The Plan says rules for a home health aide have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy. The rules say that custodial care is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a home health aide for custodial care have not been met. Specifically, this service is not covered by 
Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a home health aide for 
custodial care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs for a power wheelchair (PWC). 
 
You asked the Plan to pre-approve the PWC repairs. You say that this PWC is necessary to allow for 
completion of daily living activities. The Plan denied your request. The Plan says the documentation does not 
support that a PWC is needed; therefore, the repairs are not covered. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 PWC repairs. Our reviewer says 
that the documentation does not show that the PWC is medically reasonable and necessary. Our physician 
reviewer found the documentation does not reveal that the patient has a personal mobility deficit that impairs 
participation in MRADLs in the home. The patient's mobility deficit is currently helped by a prosthesis. The 
documentation is not clear that the requested mobility device can be safely maneuvered in the patient's home. 
 
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 PWC repairs have not been met. Therefore, we decided that the Plan does 
not have to pre-approve repairs for a power wheelchair (PWC).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lipid panel provided on May 20, 2020. 
 
You asked the Plan to pay for the lipid panel. 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 lipid panel testing at issue in this appeal was 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 
lipid panel provided on May 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 29. 
 
You asked the Plan to pre-approve the dental service. You say that you received a root canal and crown for 
tooth # 29 in July 2016. You also say that you are 10 months away from this benefit being allowed again. The 
Plan denied your request. The Plan says 1 crown per tooth is covered every 5 years. The Plan 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 and crowns are a covered service, the 
frequency limit has been reached. The record shows that you received a crown for this tooth on July 6, 2016. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 29.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ER visit provided on June 10, 2020. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you had no choice but to go to the ER 
for a scan because the Plan was taking too long to approve one. 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 $120 
copayment for emergency care.  
 
You have been asked to pay a $120 copayment for an ER visit. An ER visit falls within the emergency care 
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 ER visit provided on June 10, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (64640). 
 
You asked the Plan to pre-approve genicular nerve radiofrequency ablation. You say that please review the 
records and reverse the claim approving this appeal expeditiously. The Plan denied your request. The Plan says 
this procedure is considered experimental and investigational and is still being studied to determine if it is a 
safe and effective alternative treatment to standard therapies. 
 
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 genicular nerve radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve radiofrequency ablation (64640).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on 
April 4, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says there is no itemized billing/shipping invoice to verify the services billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a proof of delivery to support medical necessity for the supplies provided in this 
case. There is no itemized billing/shipping invoice to verify the services billed. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on April 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on January 16, 2019 and 
billed under codes 80307 and G0481. 
 
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 the documentation submitted did not include a valid physician order/lab requisition or 
medical records (signed by the ordering physician) stating exactly what tests are to be performed. The Plan 
notes that multiple attempts were made to obtain additional information from the provider. 
 
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of 
testing. The physicians order and the medical records must specifically show how this testing will be used to 
treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for 
screening purposes.
 
Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan 
does not have to pay for drug testing provided to the enrollee on January 16, 2019 and billed under codes 
80307 and G0481.
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 you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and coinsurance for a pneumatic full leg splint 
(L4370) received on May 22, 2020. 
 
You asked the Plan to waive the deductible and coinsurance for a pneumatic full leg splint. You say that you 
don't understand why you're being billed so much for this item while the Plan is covering only cents. The Plan 
denied your request. The Plan says the correct cost-sharing was applied. 
 
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 a $325 deductible and 20% coinsurance for durable medical equipment.  
 
You have been asked to pay $122.20 toward your deductible for a pneumatic full leg splint. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $325 deductible applicable to items 
and services including durable medical equipment. This cost sharing is a contractual obligation that had not 
been met at the time a pneumatic full leg splint was received on May 22, 2020. 
 
You have also been asked to pay $0.09, or 20% coinsurance of the Plan-allowed amount $0.43 left after 
satisfying the deductible, for a pneumatic full leg splint. A pneumatic full leg splint falls within the "Durable 
Medical Equipment (DME) and Related 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 deductible and coinsurance for a pneumatic full 
leg splint (L4370) received on May 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex, interspinous and/or interlaminar device 
(22869, 22870). 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not 
been met. 
 
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 Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the device 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex, interspinous and/or interlaminar device (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial. 
 
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. Medicare rules say that an SCS is covered when specific criteria are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic neck pain and 
cervical radiculopathy. She has not had any cervical spine surgery. She does not have an evidence-based 
indication for the SCS trial. The services are not reasonable or medically necessary at this time. 
 
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 a spinal cord stimulator (SCS) trial.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses purchased on May 28, 2020. 
 
You asked the Plan to pay for this eyewear. You say that you were told these lenses would be covered. The 
Plan denied your request. The Plan says claims for deluxe frames, tri-focal lenses, an eye exam and refraction 
were submitted. The total for all claims submitted by the provider was $560. The vision benefit was $150. The 
$280 cost for eyewear was denied as the vision benefit had been exhausted. 
 
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 $150 towards the cost of eyewear. Anything above $150 is your financial 
responsibility. Therefore, we decided that the Plan does not have to pay for progressive lenses purchased on 
May 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor/reader/flash monitoring 
system. 
 
You asked the Plan to pre-approve a Freestyle Libre 14 day sensor/reader/flash monitoring system. 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 item. 
 
The Plan must follow Medicare rules. Medicare rules say that continuous glucose monitors are only covered for 
certain indications. 
 
We looked at the file and Medicare rules. Review of the file does not support that you perform frequent blood 
glucose testing (four or more times a day), that your insulin regimen requires frequent adjustment based on 
blood glucose monitoring, or that you are treated with multiple (three or more) daily injections of insulin. 
Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 14 day 
sensor/reader/flash monitoring system have not been met.  
 
 
 
 
 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor/reader/flash 
monitoring system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill. 
 
You asked the Plan to pre-approve the special supplemental benefits for the chronically ill. You say that you 
would like reconsideration because this service has been denied. The Plan denied your request. The Plan says 
you do not meet any of the coverage criteria for this benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. The Plan offers a supplemental benefit for the chronically ill. 
You must meet specific criteria to be eligible for this benefit. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan rules for 
coverage of the special supplemental benefits for the chronically ill have not been met. Specifically, the 
documentation submitted by your doctor indicates that you do not have any of the qualifying chronic 
conditions, have a high risk of hospitalization or other adverse health outcomes or require intensive care 
coordination. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits 
for the chronically ill.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. The Plan denied your request. The Plan says this 
requested exceeds the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 50 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the requested additional trips will exceed the Plan maximum benefit for coverage of routine transportation. 
Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a pneumatic compression device (E0652). 
 
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the 
device. The Plan denied your request. The Plan says the documentation failed to prove that sufficient evidence 
of four-week trial using the basic pump that Medicare requires. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
 
 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device 
(E0652).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for CT Scan of the head (70450) provided on May 29, 2020. 
 
You asked the Plan to pay for the CT Scan of the head. You say that you would like reconsideration as this is 
not a duplicate claim. The Plan denied your request. The Plan says that this is a column II procedure to the 
column I procedure, 70496, billed by different provider. 
 
The Plan must follow Medicare rules. Medicare rules say that MACs subject all line items for the same 
beneficiary, same NPI, and same date of service to NCCI edits. 
 
We find that CPT code 70450 is supported in the record. Specifically, CPT code 70450 was rendered and billed 
by a different provider than who performed the column I code 70496. It is not appropriate to apply NCCI edits 
to services rendered by providers with separate NPIs. Based on this information, we decided that Medicare 
rules for coverage of the CT Scan of the head have been met. Therefore, we decided that the Plan has to pay for 
CT Scan of the head (70450) provided on May 29, 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endoscopic decompression (62380). 
 
You asked the Plan to pre-approve endoscopic decompression. You say that the records provided should 
support the necessity of the service in dispute. The Plan denied your request. The Plan says this 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. 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 endoscopic decompression have not been met. Therefore, we decided that the Plan does not have to 
pre-approve endoscopic decompression (62380).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve out-of-network surgery (22595, 22840, 20930, 61783) 
at the in-network benefit level. 
 
You asked the Plan to pre-approve a network exception.. You say that you need this surgery. The Plan denied 
your request. The Plan says these services are available in-network. 
 
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 if you choose to have 
services provided out of network your cost share will be higher. The Plan has confirmed that these service can 
be provided in network. We do not find any exception that would require the Plan to approve these out-of-
network services at the in-network level. Therefore, we decided that the Plan does not have to pre-approve out-
of-network surgery (22595, 22840, 20930, 61783) at the in-network benefit level.