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

 
We decided that the Plan does not have to pre-approve the CardioMEMS system for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is not enough evidence showing the requested device would 
improve the outcome for the enrollee's condition. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There remains a 
dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this patients clinical management. Our physician reviewer 
found that the enrollee's condition does not meet criteria for coverage of these services. 
 
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 the CardioMEMS system for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the records provided support the need for 
a portable ventilator. You say that continuous positive airway pressure (CPAP) and bilevel positive airway 
pressure (BiPAP) are not appropriate devices for the enrollee in the home setting. The Plan denied your 
request. The Plan says providers did not submit a compelling rationale that supports use of a home mechanical 
ventilator to deliver this assistance rather than a bilevel positive airway pressure (BiPAP) with a backup rate 
and average volume-asssured pressure support (AVAPS.) The Plan says that there is no documentation to 
suggest a BiPAP with backup rate and AVAPS was utilized and failed. 
 
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 a portable ventilator. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the record indicates the enrollee 
has chronic respiratory failure from chronic obstructive pulmonary disease.  The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a BiPAP machine with AVAPS capability.  The Plan has indicated 
coverage for such a device is available upon request. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the emergency ambulance transportation services (A0429, A0425) 
provided on December 8, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that these services were medically necessary 
and should be covered by your Plan. The Plan denied your request. The Plan says that the services on this claim 
were billed with the GY modifier, which means they are excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, there is no evidence that the Plan has requested medical records or 
attempted to review whether the GY modifier was used appropriately in this case. Without this review the 
Plans denial is not substantiated as items/services billed with the GY modifier are still subject to review. 
Therefore, we decided that the Plan has to pay for the emergency ambulance transportation services (A0429, 
A0425) provided on December 8, 2021.  
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hair replacement treatment. 
 
You asked the Plan to pre-approve the hair replacement treatment. You say that you suffer from alopecia and 
have been using Hair club services for the past 6 years. You say that, because alopecia is a medical condition, 
the requested treatment should not be considered cosmetic. You say that you have a wig type hair piece that 
you need to have cleaned every 5 to 6 weeks. You say that this costs you $3,000 a year and that you are on a 
fixed income. The Plan denied your request. The Plan says the requested treatment is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
We looked at the file and Medicare rules. In this case, the hair replacement treatment does not serve a medical 
purpose and is considered a cosmetic in nature. Therefore, we decided that the Plan does not have to pre-
approve hair replacement treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral examination (D0150) provided on 
March 31, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the service provided has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the service provided was exhausted on date of service February 2, 2022. Specifically, 
the Plan contract states that a comprehensive oral exam is covered once every thirty six months. You 
previously received this service on February 2, 2022, which was paid for by the Plan. Therefore, you have 
exhausted the allowable benefit for this service. Therefore, we decided that the Plan does not have to pay for 
the comprehensive oral examination (D0150) provided on March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330), the periodic oral 
evaluation (D0120), and the dental cleaning (D1110) provided on February 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the dental services were received from 
an out-of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the services provided in this case are not covered under this 
benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to 
pay for the panoramic radiographic image (D0330), the periodic oral evaluation (D0120), and the dental 
cleaning (D1110) provided on February 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided April 1, 2022. 
 
You asked the Plan to pay for the orthosis. You say that the claim met all Medicare durable medical equipment 
guidelines for payment. Medicare would have paid this claim, so the Plan needs to pay the claim as well. 
 The Plan denied your request. The Plan says the services are not documented in the enrollee's medical records.  
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 pay for the orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the physical examination findings and history do not support the use of a lumbar brace which 
does not have current quality evidence to support its use for preventing pain. There were no objective signs of 
instability or documented plans for surgery or other indication that might justify its use. Also, there was no 
documentation of current prescribed efforts with physical therapy, home exercises. Therefore, without 
sufficient support made, the lumbar brace will be considered not 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 the orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for the lumbar-sacral orthosis (L0650) provided April 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve all lower extremity prostheses, flex-walk system or 
equal (CPT code L5981). 
 
You asked the Plan to pre-approve the item. You say that the item is necessary. The Plan denied your request. 
The Plan says a replacement prosthesis has been approved for you. The Plan states the records they have do not 
show why the requested advanced foot is needed. The Plan states a request for a foot that meet your needs and 
Medicare rules can be reviewed if submitted. 
 
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 item. Our physician reviewer found 
the Health Plan has authorized a replacement prosthesis. The documentation from the medical provider does 
not indicate you require the requested advanced foot component. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve all lower extremity prostheses, flex-walk system or equal (CPT code L5981).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower extremity prosthesis, endoskeletal 
knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s) 
(L5859). 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that there is no documentation the enrollee has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or quadriceps function that impairs K-3 level function with 
the use of a microprocessor-controlled knee alone. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is no 
documented comorbidity of hip or spine. Our physician reviewer found that your condition does not meet 
criteria for coverage of these services. 
 
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 an addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and 
programmable flexion/extension assist control, includes any type motor(s) (L5859).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services billed for date of services on October 25, 
2021. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports the billed charges. 
The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
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 44120 is enterectomy, resection of small intestine; single 
resection and anastomosis. The CPT Code Manual definition of code 20680 is removal of implant; deep (e.g., 
buried wire, pin, screw, metal band, nail, rod or plate).  
 We find that CPT codes 44120 and 20680 are not supported in the medical record. Specifically, the billed date 
of service does not reflect when the services were provided. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for the surgery services billed for date of services on October 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that if the services remain denied it could 
potentially jeopardize the members health and life. The Plan denied your request. The Plan says that the 
enrollee is receiving the care he needs in the hospital where he is now. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where he is currently 
receiving care. All medically necessary care is being provided in the current acute care setting. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA Molecular Signature test provided on 
December 16, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically 
necessary. 
 The Plan follows Medicare rules. Medicare rules say that pharmacogenomics testing is covered for the 
indications established in the applicable LCD. 
 
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 testing. Our reviewer says that the 
requested testing is not medically reasonable and necessary in this case. Our physician reviewer found that the 
clinical value and effectiveness of the PrismRA Molecular Signature test in the setting of rheumatoid arthritis 
has not been demonstrated in the peer reviewed literature. The requested genetic testing at issue in this case is 
not medically reasonable or necessary according to the coverage criteria established in the applicable LCD. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the PrismRA Molecular Signature test provided on December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic service consultation (D9310), endodontic 
therapy (D3330), and amalgam (D2140), provided by an out-of-network provider on April 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed this dental work done. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, D2140 is not covered under this benefit when received 
from an out-of-network provider. The Plan does not cover D9310 or D3330. Therefore, we decided that the 
Plan does not have to pay for a diagnostic service consultation (D9310), endodontic therapy (D3330), and 
amalgam (D2140), provided by an out-of-network provider on April 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable 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 request for a home mechanical ventilator with settings that could be delivered 
by bilateral positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) for this 
member with COPD is not covered. 
 
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 that the record 
indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The 
provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS 
capability. The plan has indicated coverage for such a device is available upon request. The elements of the 
coverage criteria are not satisfied. 
 
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 portable ventilator for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter (E0118). 
 
You asked the Plan to pre-approve a knee scooter. You say that you cannot use crutches. The Plan denied your 
request. The Plan says that items that do not primarily serve a medical purpose and which are not reasonable 
and necessary to treat an illness or injury are not covered under any condition. 
 
The Plan must follow Medicare rules. Medicare rules say that there is insufficient published clinical literature 
demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for crutch 
substitutes (E0118). 
 
We looked at the file and Medicare rules. The DME MAC, the contractor responsible for coverage of medical 
equipment in the State of California has decided that the knee scooter coded as E0118 is not medically 
reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of a knee 
scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee scooter 
(E0118).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on January 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that claims were previously paid for the enrollee. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by the enrollees supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows the requested dental services were provided from an out-of-network provider. Though the 
Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered 
under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not 
have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) provided on January 5, 2022.