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

 
We decided that the Plan does not have to pre-approve a bioimpedance spectroscopy (BIS) (ImpediMed L-Dex 
device) (93702). 
 
You asked the Plan to pre-approve an ImpediMed L-Dex device. You say that you believe the use of 
ImpediMed's L-Dex device is medically necessary. The Plan denied your request. The Plan says although the 
provider states that the enrollee is at high risk for developing lymphedema, there is no high-quality evidence 
that shows that bioimpedance spectroscopy improves outcomes in Medicare beneficiaries compared to the 
standard of care. 
 
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 an ImpediMed L-Dex device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record indicates that the enrollee has a history of breast cancer. The 
record indicates that the enrollee does not have edema. Our reviewer found that the safety and efficacy of the 
requested service to be used in the enrollee's clinical condition has not been established. The record provided 
does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested 
service. Our physician reviewer also found that the elements of the coverage criteria are not satisfied, and the 
requested service is not recommended.  
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 ImpediMed L-Dex device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bioimpedance spectroscopy (BIS) (ImpediMed L-Dex device) (93702).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve Vertiflex. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the safety and efficacy of this procedure have not been established. 
 
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. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Food & Drug Administration (FDA) contraindications to this procedure including spinal 
instability, scoliosis, obesity, and osteoporosis have not been adequately addressed. There is imaging evidence 
of anterolisthesis with slippage at the L5/S1 level, with no discussion of spinal instability of flexion/extension 
films. There is no discussion of scoliosis of the lumbar spine or documentation of the Cobb angle. There is no 
compelling rationale or extenuating circumstance noted to support the necessity of this request as an exception 
to guidelines. 
 
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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital visit provided on March 14, 2022, to 
May 13, 2022. 
 
You asked the Plan to pay for an inpatient hospital visit. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an inpatient hospital 
visit provided on March 14, 2022, to May 13, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a crown (D2740) for tooth 20 provided on October 26, 2022. 
 
You asked the Plan to pay for the dental service. You say that the provider was approved to do the crown but 
the Plan denied payment. The Plan denied your request. The Plan says that this cost sharing was charged 
correctly because the Plan is the secondary insurance. 
 
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 enrollees must pay a 50% coinsurance after $100 deductible for class 3 major 
services.  
 
The Plan says you must pay $363 for the dental service. Based on the Plan contract, however, you cannot be 
asked to pay more than a 50% coinsurance after $100 deductible for the dental service. The primary insurers 
allowed amount for the crown was $993, and they paid $630. The remaining balance of the allowed amount 
due is $363. This is less than the secondary insurances allowed amount for the crown of $496.50. The Plan 
should apply the dental benefits to the $363 of the remaining balance. With a $100 deductible the balance 
would be $263 ($363 balance - $100 deductible). Then the coinsurance amount would be $131.50 ($263 
balance x 50% coinsurance). In total the enrollees liability would be $231.50 ($100 deductible + $131.50 
coinsurance) and the Plans payment should be $131.50. Therefore, we decided that the Plan has to pay 
$131.50 for the crown (D2740) for tooth 20 provided on October 26, 2022.  
 
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 pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the continuation of medically necessary 
acute care services for the enrollee is defined and demonstrates an LTACH medically appropriate admission 
per CMS definition. The Plan denied your request. The Plan says the enrollee does not have clinical conditions 
that cannot be appropriately treated in the current hospital, and there are no issues for which LTACH may offer 
a therapeutic advantage. 
 
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. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 
 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.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the abdomen. 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is necessary to see if the stents are 
functioning correctly. The Plan denied your request. The Plan says a computed tomography (CT) scan can be 
done for the enrollee's condition. 
 
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 the MRI. Our reviewer says that the 
MRI of the abdomen is not medically necessary. Our physician reviewer found that a CT scan can be done to 
determine whether the pyelonephritis and hydronephrosis has improved following stent placement. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the abdomen.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the take-home supply of buprenorphine provided on September 5, 
2022. 
 
You asked the Plan to pay for the take-home supply of buprenorphine. You say that the Plan did not have all 
the necessary information to process your claims correctly. The Plan denied your request. The Plan says that 
payment is not allowed for this claim because it does not meet the opioid treatment program criteria for 
payment. 
 
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. The Plan says that coverage for opioid treatment program services is only 
available when provided by a facility such as a freestanding opioid treatment program facility. The claim 
supports that the service is being billed by such a freestanding opioid treatment program facility. Though a 
physician is noted as the rendering provider, payment is being made to the opioid treatment program for the 
services, as is required by the rules. We find that the Plan has not substantiated the denial of payment for these 
services. Therefore, we decided that the Plan has to pay for the take-home supply of buprenorphine provided on 
September 5, 2022.  
 
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: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you just had open heart surgery and very weak, 
regular rehabilitation nursing home will not help you get stronger. The Plan denied your request. The Plan says 
that your records do not show that you have complex rehabilitation needs requiring frequent evaluation by a 
rehabilitation doctor, medically necessary care may be provided safely in a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found you do require treatment by multiple therapies, including either physical or occupational therapy, and an 
intensive rehabilitation therapy program at least three hours a day and five days a week, or 15 hours over seven 
consecutive days. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the abdomen and 
pelvis (74177). 
 
You asked the Plan to pre-approve a CT of the abdomen and pelvis. The Plan denied your request. The Plan 
says the results of the prior approved study did not show the need for repeat imaging. 
 
The Plan must follow Medicare rules. 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 a CT of the abdomen and pelvis. Our 
reviewer says that a CT of the abdomen and pelvis is not medically reasonable and necessary for the enrollee. 
Our physician reviewer found the enrollee was seen in the emergency department (ED) on January 11, 2023, 
and had CT of the abdomen and pelvis which showed a number of abnormal findings, but all were unchanged 
over serial CT exams, the most recent of which was October 22, 2022. The discharge summary from the ED 
included a planned visit to pain management and a follow-up to gastrointestinal. Our reviewer found that 
neither of those follow-up appointments are in the submitted records. Our physician reviewer also found that as 
the CT findings were chronic and unchanged over time, the medical necessity for the requested CT of the 
abdomen and pelvis has not been established in the submitted records. 
 
 
 
 
 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 CT of the abdomen and pelvis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a computed tomography (CT) of the abdomen and pelvis (74177).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mammography (77067) and digital breast tomosynthesis 
(77063), provided on November 5, 2022. 
 
You asked the Plan to pay for the screening tests. You say that the service should be covered. The Plan denied 
your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on November 15, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the screening tests have not been met. Therefore, we decided that the Plan does not have to pay for the mammography (77067) and digital breast 
tomosynthesis (77063), provided on November 5, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies (electrodes) (A4595) provided on 
September 18, 2022. 
 
You asked the Plan to pay for the electrodes. You say that it is impossible for the enrollee to initiate and 
continue treatment without prescribed supplies A4595 as device's design function for treatment require said 
supplies for regimen. The Plan denied your request. The Plan says that Proof of Delivery did not include an 
order number or details to corroborate the Delivery Ticket submitted. The Plan also says the Proof of Delivery 
is not itemized to indicate the specific supplies; therefore, the billed supply code cannot be verified. 
 
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 contain a valid proof of delivery for the supplies provided in this case. Specifically, the 
packing slip with the tracking number was dated September 18, 2022, which matches the date of service at 
appeal. Therefore, we decided that the Plan has to pay for the electrical stimulator supplies (electrodes) 
(A4595) provided on September 18, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two abutment supported porcelain/ceramic crowns 
(D6058 x 2) and two prefabricated abutmentsincludes modification and placement (D6056 x 2). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plans denial. The Plan denied your request. The Plan says your request exceeds the allowable benefit for these 
dental items. 
 
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 request for the dental items exceeds the allowable dental benefit. Specifically, the Plan provides 
coverage for two implants per calendar year or four implants for endentulous patients. The Plan has previously 
authorized two abutment supported crowns and two fabricated abutments. Therefore, your request exceeds the 
allowable benefit for these items.  We decided that the Plan does not have to pre-approve two abutment supported porcelain/ceramic crowns 
(D6058 x 2) and two prefabricated abutmentsincludes modification and placement (D6056 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SSBCI. 
 
You asked the Plan to pre-approve SSBCI. You say that you do not agree with the denial of SSBCI benefits. 
The Plan denied your request. The Plan says there is no documentation that the member meets criteria. The 
Plan also says that multiple attempts were made to obtain medical records, but additional supporting 
documentation was not obtained. 
 The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI have not been met. Specifically, we decided that there is insufficient information in the 
record to determine if Medicare rules for coverage of SSBCI have been met. The record shows medical records 
were requested and not received. Without the requested medical records, we cannot determine if you do or do 
not have one of the eligible conditions listed in the EOC. Therefore, we decided that the Plan does not have to 
pre-approve SSBCI.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
porcelain/ceramic crown (D2740).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that a transfer in care will disrupt your treatment and will 
be a detriment to your health and life. The Plan denied your request. The Plan says criteria for admission to the 
Acute Inpatient Rehabilitation setting have not been met, your ongoing skilled therapy and nursing needs can 
be provided at a lower level of care such as at a Skilled Nursing Facility, on an intermittent basis at home with 
home health care, or in a long-term care setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies, including either physical or 
occupational therapy, and an intensive rehabilitation therapy program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 18, 2022.