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

 
We decided that the Plan does not have to pre-approve an MRI of the pelvis (72197). 
 
You asked the Plan to pre-approve an MRI of the pelvis (72197). You say that the requested MRI of the pelvis 
(72197) is medically necessary. The Plan denied your request. The Plan says the requested MRI of the pelvis 
(72197) is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 an MRI of the pelvis (72197). Our 
reviewer says that the requested MRI of the pelvis (72197) is not medically necessary. Our physician reviewer 
found the enrollee is diagnosed with multiple myeloma having issues with increased frequency of urination. An 
MRI of the pelvis would not be medically reasonable or necessary in this case. A workup would follow 
algorithms for lower urinary tract symptoms to include exam, blood work and trial medications. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the pelvis (72197) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an MRI of the pelvis (72197).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Coagucheck machine from an out-of-network 
provider. 
 
You asked the Plan to pre-approve the machine. You say that you have been approved for a network provider. 
The Plan denied your request. The Plan says you have been approved for a network provider. 
 
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 machine. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the medical records provided there is no documentation of any compelling evidence of 
discrepancies or incorrect data from the network device that require approval out-of-network for the device. 
 
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 machine have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Coagucheck machine from an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator for the enrollee. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records do not show a medical need for this item. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the enrollee 
has a listed diagnosis of COPD, but there are no pulmonary function data to confirm this, and the enrollee is 
quite young to have severe COPD. The most likely cause of the respiratory failure is obesity-hypoventilation 
syndrome. Medicare does not cover a home ventilator for this diagnosis. BiPAP is the appropriate treatment. 
Certain BiPAP devices are capable of providing the AVAPS-AE mode of support. A home ventilator is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750), prefabricated post and core (D2954), 
and endodontic therapy (D3310). 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the requested dental services are not medically necessary. 
 
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 dental 
services 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 dental services. Our reviewer says 
that the requested services are not medically necessary. Our physician reviewer found the criteria for coverage 
for a root canal, post/core and crown for tooth #24 have not been met due to the inadequate bone support and 
extensive coronal breakdown resulting in a poor crown root ratio.  The prognosis of the treatment is poor. 
 
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 dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2750), prefabricated post and core (D2954), and endodontic therapy 
(D3310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fluoride carriers. 
 
You asked the Plan to pre-approve the dental service. You say that the enrollee was referred by their head and 
neck surgeon. You say that after being diagnosed with squamous cell carcinoma on the base of their tongue. 
You say that this service is needed as a result of high doses of radiation to the enrollee's head and neck. You 
also say that this treatment is medically necessary. The Plan denied your request. The Plan says the dental 
treatment is not related to extraction prior to radiation or a facial fracture. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
Although the enrollee's Plan has supplemental dental coverage, the services you are asking the Plan to pre-
approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly 
supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we 
decided that the Plan does not have to pre-approve fluoride carriers.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the core buildup. You say that the enrollee is in pain, and would like 
treatment as soon as possible. The Plan denied your request. The Plan says this service is not covered by the 
enrollee's dental plan. 
 
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 a 
core buildup, including any pins when required (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a motorized wheelchair. 
 
You asked the Plan to pre-approve the motorized wheelchair. You say that you would like reconsideration 
because you have been having accidental falls using walkers. The Plan denied your request. The Plan says the 
records show you are requesting a power scooter for outside of the home use and they do not show that you are 
unable to use a walker or a wheelchair in your home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a motorized wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty walker with a seat attachment for the 
enrollee. 
 
You asked the Plan to pre-approve the walker. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence that the enrollee is unable to ambulate with a standard walker. 
 
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 walker. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found both of the provided visit notes report that the enrollee's gait is within normal limits. There is no 
documentation that the enrollee is unable to use a standard walker due a neurologic disorder or other condition. 
 
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 walker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a heavy-duty walker with a seat attachment for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan of the neck and MRI of the lower back. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no signs or symptoms concerning of a pinched nerve in the neck or lower back. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary. Medicare rules say that CT scans are covered only when they are medically 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 scan. Our reviewer says that the 
requested imaging is not medically reasonable or necessary. Our physician reviewer found the records do not 
provide any information concerning the need for cervical spine CT scan. In fact, the x-ray studies done on the 
date of injury (8/12/20) did not include a cervical spine exam. No neurological impairment of the upper 
extremities is documented. Thus, the medical necessity of the requested CT of the cervical spine is not 
established in the submitted material. The x-rays of the lumbar spine show a L1 vertebral compression fracture 
without retropulsion. There is no documented neurological compromise. The medical necessity of MRI of the 
lumbar spine is not explained per the submitted material. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CT scan of the neck and MRI of the lower back.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oral enteral products. 
 
You asked the Plan to pre-approve the products. You say that this is not medically necessary. The Plan denied 
your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan 
does not have to pre-approve oral enteral products.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLDCT for Lung Cancer Screening.You asked the Plan to pre-approvethe LDCT. You say that you would like reconsideration because the clinical information submitted is incorrect.The Plan denied your request. The Plan says the records do not show that you are a smoker or that you have quit within the last 15 years.The Plan must follow Medicare rules. Medicare rules say that for purposes of Medicare coverage of lung cancer screening with LDCT, beneficiaries mustbe current smokers or one who has quit within the last 15 years.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LDCT have not been met. Specifically, the record indicates that you are not a current smoker and that you quit in 1999.Therefore, we decided that the Plan does not have to pre-approveLDCT for Lung Cancer Screening.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve repair and revision of wrist joint for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that the enrollee has significant osteoarthritis of the 
right wrist, as well as carpal tunnel syndrome. The Plan denied your request. The Plan says that the enrollee 
was treated with medications and injections only. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 surgery. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee presents with progressively worsening right thumb pain and hand numbness. Functional 
limitations are noted in activities of daily living. Clinical exam findings have been consistent with radiological 
evidence of severe joint space narrowing and spurring with radial subluxation of the right trapeziometacarpal 
joint, and possible scaphoid trapezoid osteoarthritis. Signs/symptoms and provocative testing have also been 
consistent with right carpal tunnel syndrome. He has failed to improve with activity modification, medications, 
and cortisone injection. Under consideration is a request for right trapezium and hemi-trapezoid arthroplasties 
and right carpal tunnel release. Evidence based medical literature supports the requested right thumb surgery 
given the severity of his osteoarthritis and failure of reasonable conservative treatment. Additionally, surgical 
treatment of his carpal tunnel syndrome at the time of concurrent right thumb surgery is reasonable indicated to 
maximize functional restoration. Therefore, this request for right wrist/thumb surgery is medically reasonable 
and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgery have been met. Therefore, we decided that the Plan has to pre-
approve repair and revision of wrist joint for the enrollee.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient therapy to be provided by an out of network 
provider. 
 
You asked the Plan to pre-approve outpatient therapy. You say that there would be minimal stress going to 
therapy across the street. You say that your health would be protected, and it is medically necessary to put the 
provider in-network. The Plan denied your request. The Plan says services are available in-network. 
 
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 
outpatient therapy to be provided by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office or other outpatient visit for the evaluation and 
management of an established patient, typically, 25 minutes are spent face-to-face with the patient and/or 
family. (CPT Code 99214) provided on January 16, 2020. 
 
You asked the Plan to pay for the service. You say that the claim is not a duplicate and would like the claim 
reconsidered for payment. The Plan denied your request. The Plan says this is a duplicate claim. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Service line 99214 was processed 
and paid on another claim for the same date of service, CPT and diagnosis code, billed by the same provider. 
Therefore, we decided that the Plan does not have to pay for office or other outpatient visit for the evaluation 
and management of an established patient, typically, 25 minutes are spent face-to-face with the patient and/or 
family. (CPT Code 99214) provided on January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown (D2740) provided on December 19, 2019. 
 
You asked the Plan to pay more for the dental service. You say that you thought the crown should be covered 
at 40%. You say that you were unaware that the payment would be less because you reached your annual 
maximum. The Plan denied your request. The Plan says there is an annual maximum benefit of $1,000. The 
Plan says that the annual maximum benefit was reached in the processing of this claim. 
 
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 covered at 40%, the 
annual maximum benefit of $1,000 was reached during the processing of this service. The record shows that 
the Plan paid $69.60 towards the crown at which point the annual maximum had been reached. Therefore, we 
decided that the Plan does not have to pay more for the crown (D2740) provided on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided 
on June 19, 2020. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that the injection 
should be fully covered. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You received a Medicare Part B drug injection on June 19, 2020. The total allowed amount is $1,160.40 and 
20% of that is $232.08.  
 
You have been asked to pay the total coinsurance amount of $232.08 for a Medicare Part B drug injection. A 
Medicare Part B drug injection falls within the Medicare Part B prescription drugs benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for a Medicare Part B drug injection provided on June 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) rendered by the out of network 
(OON) provider on February 17, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the office visit (99213) rendered by the out of network (OON) provider on February 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for durable medical equipment provided by a 
participating provider on February 25, 2020, through May 31, 2020. 
 
You asked the Plan to waive the copayment for durable medical equipment. You say that you think this should 
be billed as one unit. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $10 
copayment for durable medical equipment/in-network.  
 
You have been asked to pay a $10 copayment for durable medical equipment. The total amount you are being 
asked to pay is $110. Durable medical equipment falls within the durable medical equipment/in-network 
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 durable medical equipment 
provided by a participating provider on February 25, 2020, through May 31, 2020.