Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve open toe postsurgical shoe/surgical boot/post-op ortho 
shoe (CPT code L3260). 
 
You asked the Plan to pre-approve foot orthotics. You say that the item is necessary. The Plan denied your 
request. The Plan says the enrollee does not have a brace that requires this shoe. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve open toe 
postsurgical shoe/surgical boot/post-op ortho shoe (CPT code L3260).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural (CPT code 63650) and implantable neurostimulator electrode, each (CPT code L8680). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because the enrollee's records do not show that 
this is being used as a last resort for management of their condition as additional treatment modalities (physical 
therapy, kyphoplasty, and cervical nerve blocks have not been completed, and the enrollee has not had a 
surgical evaluation or records that show that the enrollee is not a surgical candidate to support that they have 
had careful screening by a multidisciplinary team prior to the recommendation for spinal cord stimulator trial. 
 
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 physician reviewer 
found the enrollee does not meet the Budapest criteria for complex regional pain syndrome (CRPS) and have 
not had an adequate trial of physical therapy. At this point, the request is deemed 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 percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650) 
and implantable neurostimulator electrode, each (CPT code L8680).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on August 19, 2021. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says the services billed by the provider are not covered. In addition, the 
Plan reviewed the claim history for all chiropractic services provided previously. There are no claims submitted 
with the code 98941 from this provider or any other providers. Therefore, there is no evidence the Plan paid for 
this service in the past. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic 
services provided on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network visit. You say that the services are necessary. The Plan 
denied your request. The Plan says there are in-network providers who can render the services. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 out-of-network visit. Our physician reviewer found the record indicates 
that you have osteoarthritis and an elevated creatine phosphokinase (CPK) level. The record indicates that the 
plan has in-network rheumatologists that are available to see you. The record does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, for out-of-network services at this time. The 
elements of the coverage criteria are not satisfied. 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 the out-of-network visit have not been met.  
 
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 the out-of-network visit. Therefore, we decided that 
the Plan does not have to pre-approve the office visit to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar epidural steroid injection. 
 You asked the Plan to pre-approve epidural steroid injection. You say that you are appealing this denial. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because you must 
wait at least 3 months after your previous epidural injection before having a repeat injection. 
 
The Plan follows Medicare rules. Medicare rules state that repeat epidural steroid injections may be covered if 
certain criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve epidural steroid injection. Our reviewer 
says that you do not meet the Medicare criteria for the requested epidural. Our physician reviewer found your 
previous epidural steroid injection on February 3, 2022 provided 60% relief of pain. However, that injection 
has not provided pain relief for at least 3 months in duration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve lumbar epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a treadmill. 
 
You asked the Plan to pre-approve a treadmill. You say that you need this item. The Plan denied your request. 
The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a treadmill.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that you cannot walk without a hard time 
breathing and your oxygen level is up to level 5. You state if you do not get this equipment, you may have to 
go back into the hospital. The Plan denied your request. The Plan says there is no documentation that you have 
tried and failed bilevel positive airway pressure (BiPAP) ventilation. 
 
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 home ventilator. Our physician 
reviewer found a home ventilator is not medically necessary. This enrollee has a diagnosis of chronic 
obstructive pulmonary disease (COPD), although the records do not include pulmonary function tests. Arterial 
blood gases (ABG) done while hospitalized showed mild carbon dioxide (CO2) retention.  
 There is no ABG done while awake and stable as outpatient. Home bilevel positive airway pressure (BiPAP) 
has not been tried; certain devices can provide the average volume-assured pressure support (AVAPS) mode at 
less cost to you. Medicare does not cover a home ventilator when used as BiPAP. The denial is upheld. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the molecular genetic testing (CPT code(s): 81288 and 
81210). 
 
You asked the Plan to pre-approve the molecular genetic testing. You say that the services are necessary. The 
Plan denied your request. The Plan says your request is not medically necessary because the enrollee's records 
show the enrollee does not have evidence of metastatic disease. 
 
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 molecular genetic testing. Our 
physician reviewer found the provided records did not clearly show that the enrollee had metastatic disease to 
meet criteria for this testing, and there were no exceptional circumstances that would suggest testing would 
lead to improved outcomes for this particular patient based on current evidence. Therefore, this request for 
BRAF and MLH1 genetic testing 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 molecular genetic testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the molecular genetic testing (CPT code(s): 81288 and 81210).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous CGM and all related supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the CGM and supplies are necessary. 
The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM and supplies. Our physician 
reviewer found the documentation does not show that the enrollee is taking insulin at least three (3) times a day 
or use a continuous insulin pump and the documentation does not show that the enrollee requires frequent 
insulin adjustments based on their blood sugar results. 
 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 CGM and supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous CGM and all related supplies.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued skilled nursing facility (SNF) stay beyond 
100 days. 
 
You asked the Plan to pre-approve the continued SNF stay. You say that you would like the enrollee to be 
given a chance to make the most of his recovery and reinstate his physical therapy. The Plan denied your 
request. The Plan says SNF care beyond 100 days per benefit period is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from August 5, 2021, 
to November 12, 2021. The Plan has covered 100 days of SNF care.  
 
 Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve a continued skilled nursing facility (SNF) stay beyond 100 days.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement (D6010) for teeth # 6, 11, 22, and 27. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee requires these implants in 
order for her teeth to function properly. The Plan denied your request. The Plan says dental implants are 
excluded from coverage. 
 
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 implant placements are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
implant placement (D6010) for teeth # 6, 11, 22, and 27.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an EGD. 
 
You asked the Plan to pre-approve an EGD. You say an EGD is medically necessary. The Plan denied your 
request. The Plan says the additional information provided by the treating physician is not medically necessary 
since other conservative treatments have not been tried and found unsuccessful prior to the requested EGD. 
 
The Plan follows Medicare rules. Medicare rules say that endoscopy procedures can only be allowed if 
abnormal signs or symptoms or known disease are present.  
 
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 EGD. Our reviewer says that the 
EGD is not medically necessary. Our physician reviewer found that the available medical record provides 
insufficient clinical support for a high suspicion of upper gastrointestinal (GI) pathology to warrant at this time 
in her case a medically necessary EGD. The risk of EGD and sedation is substantial for this enrollee who is 
best served at this juncture with diet control, weight management, resumption of proton-pump inhibitor (PPI) 
use, and cross-sectional imaging to exclude biliary and pancreatic pathology.  
 
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 EGD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an EGD.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oral nutritional supplements for the enrollee. 
 
You asked the Plan to pre-approve oral nutritional supplements. You say that oral nutritional supplements are 
medically necessary for the enrollee. The Plan denied your request. The Plan says oral nutritional supplements 
are not covered by Medicare. 
 
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 considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve oral nutritional supplements for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on September 2, 
2021. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you owe $0 for colonoscopies. 
The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the 
correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for services obtained by a specialist.  
 
 
 You have been asked to pay a $35 copayment a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's office visits 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 a specialist visit provided on September 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation (D7953) 
for teeth # 3, 8, and 11. 
 
You asked the Plan to pre-approve the dental services. You say that these services are necessary to begin the 
process of procuring dentures. The Plan denied your request. The Plan says bone replacement graft for ridge 
preservation is not listed as a covered service. 
 
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 bone replacement graft 
for ridge preservation is not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pre-approve bone replacement graft for ridge preservation (D7953) for teeth # 3, 8, and 11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on October 20, 2021. 
 
You asked the Plan to pay for the dental service. You say that you had no information on how many visits you 
were allowed. You say that you had 3 cleanings in 2020. You also say that if you had known how many visits 
you were allowed, you would have gone to our medical doctor so that you would not have to pay. The Plan 
denied your request. The Plan says prophylaxis is covered twice per plan year. The Plan also says that the 
frequency limit has been exceeded. 
 
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 and prophylaxis is listed as covered, the 
frequency limit has been exceeded. The record shows the Plan paid for prophylaxis that you received on 
February 2, 2021, and June 7, 2021. Therefore, we decided that the Plan does not have to pay for the 
prophylaxis (D1110) provided on October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on November 1, 2021. 
 
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 had network providers available 
who could have provided 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 (99214) rendered by the out-of-network (OON) provider on  
November 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a long-handled skin inspection mirror. 
 
You asked the Plan to pre-approve a long-handled skin inspection mirror. You say that a long-handled skin 
inspection mirror is medically necessary. The Plan denied your request. The Plan says a long-handled skin 
inspection mirror is a self-help device and is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  The item requested is a self-help device and does not serve a purpose that is primarily 
medical in nature. This item is available to the public and would be helpful even to those who are not sick or 
injured. Therefore, we decided that the Plan does not have to pre-approve a long-handled skin inspection 
mirror.