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

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
December 5, 2017, to December 20, 2017. 
 
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the enrollee no 
longer required skilled 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 pay for the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that there is no documentation that the 
enrollee required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled 
professional nurse were not required to safely and effectively provide medically necessary and reasonable 
treatment from December 5, 2017, to December 20, 2017. The enrollee did not require skilled therapy services. 
Daily skilled services were not required. The enrollee did not require the services on an inpatient basis, in a 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) care provided from December 5, 2017, to December 20, 
2017.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on July 23, 2020. 
 
You asked the Plan to pay for the first intraoral periapical x-ray. You say that you believe you are only 
responsible for 50% of the bill. The Plan denied your request. The Plan says this service is not covered. 
 
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 pay for the first 
intraoral periapical x-ray provided on July 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external infusion pump and supplies. 
 
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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that an ambulatory infusion pump described by code 
E0784 is denied as not medically necessary. 
 
We looked at the file and Medicare rules. The item at issue is an ambulatory infusion pump described by code 
E0784. This item is denied by Medicare as not medically necessary. Therefore, we decided that the Plan does 
not have to pre-approve an external infusion pump and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tooth extraction to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the tooth extraction to be provided by an oral surgeon. You say that you 
would like reconsideration because you were told you need an oral surgeon to perform this tooth extraction. 
The Plan denied your request. The Plan says this service is only covered when performed 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, the requested items or services are not 
among those covered under this benefit. Specifically, the services of an oral surgeon are not covered under your 
contract with the Plan. Therefore, we decided that the Plan does not have to pre-approve a tooth extraction to 
be provided by an oral surgeon.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Somatuline Depot (J1930). 
 
You asked the Plan to pre-approve Somatuline Depot. You say that the services are necessary. The Plan denied 
your request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Somatuline Depot. Our reviewer says 
that the medication is medically necessary. Our physician reviewer found while not FDA indicated, there are 
published studies about the benefit, in some patients, of lanreotide in the setting of angiodysplasia, specifically 
reduced use of medical facilities. The enrollee is higher risk for the standard of care treatment with endoscopy 
due to problems from a respiratory standpoint with sedation. It is indicated as part of the palliative care plan as 
it may prevent/reduce hospitalizations and utilization based on less blood loss. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Somatuline Depot have been met. Therefore, we decided that the Plan has to 
pre-approve Somatuline Depot (J1930).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided 
from April 15, 2020 through April 19, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. The Plan denied your request. 
The Plan says that copayments are a contractual obligation and cannot be waived. 
 
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 $225 
copayment for each day for days 1 to 6 for Medicare-covered hospital care.  
 
You have been asked to pay a $900 copayment for the inpatient hospital services. The inpatient hospital 
services fall within the days 1 to 6 for Medicare-covered hospital 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 the inpatient hospital services provided from April 15, 2020 through 
April 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet nerve neurolysis for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan has no contractual obligation to cover services that are not reasonable and 
necessary. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the duration of the prior pain relief is not documented. Without this data, the requested procedure cannot 
be supported. At this point, this request 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet nerve neurolysis for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 18, 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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on May 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the requested provider gives the best advice. 
The Plan denied your request. The Plan says the services are available within the 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
ophthalmology 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 maxillary partial denture - resin base. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
maxillary partial denture - resin base.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute. 
 
You asked the Plan to pre-approve these services. You say that you are not strong enough for regular crutches. 
The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a crutch substitute is not medically necessary. 
 
We looked at the file and Medicare rules. The item at issue is a crutch substitute. This item is denied by 
Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pre-approve a crutch 
substitute.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglass frames (V2020), trifocal lenses (V2300),  
anti-reflective coating per lens (V2750), vision miscellaneous item (V2799), and the contact lenses (V2500) 
provided on June 8, 2020. 
 
 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the items purchased are not covered as you have 
exceeded the routine vision benefit for the calendar year.  
 
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. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, you received routine eyewear on June 10, 2019. The 
routine vision benefit is administered on a rolling calendar year from the last date of service. You had 
exhausted the vision benefit and were not eligible for vision services until June 10, 2020. Therefore, we 
decided that the Plan does not have to pay for the eyeglass frames (V2020), trifocal lenses (V2300),  
anti-reflective coating per lens (V2750), vision miscellaneous item (V2799), and the contact lenses (V2500) 
provided on June 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device 
(Superion Vertiflex). 
 
You asked the Plan to pre-approve Vertiflex procedure. You say that Vertiflex would provide significant 
clinical and quality of life benefits for the enrollee while minimizing complications and risks. The Plan denied 
your request. The Plan says the denial of authorization for this service is correct, because there is a lack of 
evidence to support that Vertiflex is as safe and effective as the gold standard of decompression. 
 
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 Vertiflex procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a review of the literature indicates that large, well-designed studies in the peer-
reviewed scientific literature comparing standalone use of Vertiflex to established surgical decompression are 
needed. At this time the Vertiflex procedure does not demonstrate long-term superiority over standard surgical 
treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve insertion of an interlaminar stabilization device (Superion Vertiflex).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tremfya (J1628). 
 
You asked the Plan to pre-approve Tremfya. You say that this medication is the best option for you. The Plan 
denied your request. The Plan says coverage of this medication is the responsibility of you prescription drug 
plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tremfya (J1628).  
 
Benefits for Tremfya may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services (99283) provided 
on March 13, 2019. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you should not be 
responsible for the copay. The Plan denied your request. The Plan says the copay was applied correctly. 
 
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 $90 
copay for emergency care.  
 
You have been asked to pay a $90 copay for emergency room services. This service 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 emergency room services 
(99283) provided on March 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain management services rendered on July 9, 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. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 64635 is 1. You billed 2 units of this code, exceeding the MUE. 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 pain management services rendered on July 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a cystourethroscopy (52234) provided on February 17, 2020. 
 
You asked the Plan to pay for a cystourethroscopy. You say that this is supported by the records. The Plan 
denied your request. The Plan says there is insufficient documentation to corroborate the services. 
 
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 CPT Code Manual definition of code 52234 is cystourethroscopy, with fulguration (including 
cryosurgery or laser surgery) and/or resection of; small bladder tumor(s) (0.5 up to 2.0 cm). 
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 pay for a cystourethroscopy. Our reviewer says that 
this code is not supported. Our physician reviewer found the operative report does not document size of tumor 
removed; therefore, the billed CPT code cannot be verified. 
 
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 cystourethroscopy have not been met. Therefore, we decided that the Plan 
does not have to pay for a cystourethroscopy (52234) provided on February 17, 2020.
Appeal type: Transportation
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. You say that this should be reconsidered. The Plan 
denied your request. The Plan says the 51st trip and beyond is not a covered benefit. 
 
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 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted 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 pre-approve continuous positive airway pressure (CPAP) supplies. 
 
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 request exceeds the allowed limit. 
 
The Plan must follow Medicare rules. Medicare rules say that CPAP supplies beyond the allowed limit are 
denied as not medically necessary. 
We looked at the file and Medicare rules. The services at issue are six filters, three face mask interfaces, one 
nasal interface, one tubing with integrated heating, one water chamber for humidifier, and one headgear. These 
services are being requested in excess of the amounts allowed by Medicare and are denied as not medically 
necessary. Therefore, we decided that the Plan does not have to pre-approve continuous positive airway 
pressure (CPAP) supplies.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient surgery for insertion of interspinous and/or 
interlaminar device (22869). 
 
You asked the Plan to pre-approve the interspinous and/or interlaminar device. You say that it is your 
professional opinion that the Vertiflex procedure would provide significant clinical and quality of life benefits 
for the enrollee while minimizing complications and risk. The Plan denied your request. The Plan says this 
procedure is experimental, investigational and/or unproven as medical studies have not proven that the device 
is helpful for the treatment of the enrollee's health problem. 
 
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 interspinous and/or interlaminar device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve outpatient surgery for insertion of interspinous and/or interlaminar device (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on March 11, 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 procedure code 99152 is not supported. 
 
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 CPT Code Manual definition of code 99152 is moderate sedation services by physician also 
performing a procedure, patient 5 years of age or older, first 15 minutes. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of 
an independent trained observer to assist in monitoring the patient's level of consciousness and physiological 
status. 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 moderate sedation services rendered on 
March 11, 2020.