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

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466) and accessories (E0562, 
A7013, A7037, A7035, A7046, A7030). 
 
You asked the Plan to pre-approve a home ventilator and accessories. You say that the ventilator is to be used 
for the treatment of COPD. The Plan denied your request. The Plan says the request for a home mechanical 
ventilator set in VAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP 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 a home ventilator and accessories. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has COPD 
and severe obesity and was recently hospitalized with a COPD exacerbation. ABG was consistent with acute on 
chronic CO2 retention, and a ventilator was ordered at discharge. The enrollee may benefit from BiPAP, with 
or without AVAPS, during sleep. Medicare does not cover a home ventilator when used as BiPAP. 
 
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 home ventilator and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a home ventilator (E0466) and accessories (E0562, A7013, A7037, 
A7035, A7046, A7030).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services (0037U) provided on December 17, 2020. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says that there was insufficient information provided to review why this test was 
ordered or how it will impact the enrollee's treatment. 
 
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 indicates this claim was denied due to lack of information. However, 
the file does not include evidence that the Plan has made reasonable and diligent efforts to obtain this 
information. Therefore, we decided that the Plan has to pay for the lab services (0037U) provided on December 
17, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026) provided on June 21, 2022. 
 
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 this service is not a covered benefit. 
 The Plan must follow Medicare rules. Medicare rules say that that there is sufficient evidence to conclude the 
use of infrared therapy devices and any related accessories is not reasonable and necessary. The use of infrared 
and/or near-infrared light and/or heat, including monochromatic infrared energy, is non-covered for the 
treatment, including the symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic 
peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the infrared therapy service provided have not been met. Specifically, Medicare rules say that there is sufficient 
evidence to conclude that the use of infrared therapy devices and any related accessories is not reasonable and 
necessary. Therefore, we decided that the Plan does not have to pay for the infrared therapy (97026) provided 
on June 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that you were recommended to see this physician by your glaucoma specialist and your 
optometrist. You say that you do not want to go to the redirected in-network provider because the provider does 
not seem skilled enough to handle your medical condition. The Plan denied your request. The Plan says you 
should receive care from a provider within the network that is contracted for these services except if an 
emergency exists or if services are not available. The service is available with an in-network oculoplastic 
surgeon provider. 
 
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 services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower extremity, varus/valgus correction 
strap (L2270), an addition to lower extremity, varus/valgus correction, plastic modification (L2275) and an 
addition to lower extremity, prosthetic type, (bk) socket, molded to patient model (L2350). 
 
You asked the Plan to pre-approve prosthetics. You say that the codes and their associated modifications are 
necessary for the item ordered. Each code represents an integral part of the device and will not function 
properly for the enrollee unless all are included. The Plan denied your request. The Plan says the recommended 
price data analysis and coding (PDAC) codes for this brace do not include the codes submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate coding. 
 
 
 We find that CPT code L2270, L2275, L2350 is not supported in the medical record. Specifically, PDAC is a 
contractor with Medicare that approves and maintains a list of medical equipment and supplies. The records 
show the provider is requesting the Arizona Brace Unweighting. The requested items are not approved by 
PDAC and therefore, not covered with your plan. Based on this information, we decided that Medicare rules 
for coverage of prosthetics have not been met. Therefore, we decided that the Plan does not have to pre-
approve an addition to lower extremity, varus/valgus correction strap (L2270), an addition to lower extremity, 
varus/valgus correction, plastic modification (L2275) and an addition to lower extremity, prosthetic type, (bk) 
socket, molded to patient model (L2350).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Percutaneous Vertebral Augmentation (PVA). 
 
You asked the Plan to pre-approve the PVA procedure. You say that this procedure is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PVA is covered when there is acute (less than 6 
weeks) or sub-acute (6-12 weeks) osteoporotic vertical compression fracture.  
 
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 PVA procedure. Our reviewer says 
that this procedure is not medically necessary. Our physician reviewer found the record shows the fracture 
occurred 16 weeks ago. The injury is not recent enough to meet coverage rules. 
 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 PVA procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Percutaneous Vertebral Augmentation (PVA).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a transthoracic echocardiography (TTE) (93306). 
 
You asked the Plan to pre-approve a TTE. You say that the test is medically necessary for the enrollee's health 
condition. The Plan denied your request. The Plan says that the enrollee does not meet criteria for the requested 
testing. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a TTE. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found at issue is the medical necessity of a TTE in an enrollee with recent-onset atrial fibrillation. A 
radionuclide stress test is negative. Clinical guidelines support the performance of a TTE in this setting. In 
summary, it is appropriate and reasonable to carry out a TTE in this enrollee's clinical management. 
 
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 TTE have been met. Therefore, we decided that the Plan has to pre-approve a 
transthoracic echocardiography (TTE) (93306).  
 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 pay for a limited oral evaluation (D0140), the re-cement or re-bond 
of a crown (D2920) provided from March 10, 2022, to May 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that there is not a contracted dentist within 50 miles 
of your home. You also say that this is your family dentist. 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, a limited oral evaluation (D0140) is not covered under 
this benefit. The re-cement or re-bond of a crown (D2920) is not covered under this benefit when received from 
an out-of-network provider. Also, please note that the record shows there are in-network providers available 
within a 45-60 mile radius of your home address. Therefore, we decided that the Plan does not have to pay for a 
limited oral evaluation (D0140), the re-cement or re-bond of a crown (D2920) provided from March 10, 2022, 
to May 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by the requested out-of-
network provider. 
 
You asked the Plan to pre-approve an office visit to be provided by the requested out-of-network provider. You 
say that the provider implanted a spinal stimulator in your back in January of 2020 and you need to have it 
removed.  The Plan denied your request. The Plan says there are in-network providers available that can 
provide this service. You may still see the requested out-of-network provider using your out of-network 
benefit. 
 
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 services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit and lesion destruction 
provided on June 30, 2022. 
 
You asked the Plan to waive the deductible for the office visit and lesion destruction. You say that you feel 
your obligation is incorrect for these services. The Plan denied your request. The Plan says this cost sharing 
was charged 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 $800 
deductible for doctor and other health care provider services. 
 
You have been asked to pay a $800 deductible for the office visit and lesion destruction. This item/service falls 
within the doctor and other health care provider services 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 deductible for the office visit and lesion destruction provided on June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a maxillary partial denture (D5213) provided on June 
3, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you did not know this provider was out-
of-network at the beginning. You also say that this provider is the only dentist and prosthodontist within a 
reasonable distance. The Plan denied your request. The Plan says you are responsible for any charged amount 
above the Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The 
record shows that there are seven in-network prosthodontists within 30 miles of your address. Therefore, we 
decided that the Plan does not have to pay more for a maxillary partial denture (D5213) provided on June 3, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy. 
 
You asked the Plan to pre-approve image-guided radiation therapy. You say that due to mitigating factors such 
as tissue mobility, location of the lesion and the members medical history of dementia with associated 
cognitive decline and diabetes with associated difficulty healing and post-surgical complications so image-
guided superficial radiation therapy (IG-SRT) was ordered. The Plan denied your request. The Plan says the 
member did not meet the medical necessity criteria required for coverage of Image-guided radiation therapy. 
 
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 image-guided radiation therapy. Our 
reviewer says that the requested image-guided radiation therapy is not considered medically reasonable and 
necessary in this case. Our physician reviewer found radiation is a standard approach to the treatment of skin 
cancer and is often preferred over surgery when resection is likely to result in unacceptable morbidity or 
cosmesis. The use of superficial radiotherapy (SRT) or electronic brachytherapy for skin cancers that would be 
well-treated with standard radiotherapy modalities such as electron therapy or orthovoltage radiotherapy.  The 
most recent v2.2022 NCCN guidelines for basal cell and squamous cell skin cancers explicitly state There are insufficient long-term efficacy and safety data to support routine use of electronic surface brachytherapy. 
However, the treatment itself is not disputed in this case but rather the need for image guidance. At issue is the 
need for daily image guidance; it appears that the request is for IGRT. IGRT is a means to improve set-up 
accuracy. IGRT uses daily image guidance to help localize the target so as to minimize normal tissue dosing. 
Specifically, IGRT allows accuracy of treatment delivery, so when generating a planning target margin, the 
margins can be reduced, and thus allow reduction in the volume of normal tissues exposed to radiation. Usually 
IGRT is used when critical structures are abutting or in close proximity to the target that is being treated to high 
doses. This situation does not apply to this enrollee for which the target lesion can be seen on the skin to assist 
in daily set up. When treating skin cancers, there is generally not a need for IGRT unless deep structures are 
being treated.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of image-guided radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve image-guided radiation therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical imaging (D0220 and D0230), a comprehensive 
oral evaluation (D0150), and bitewings (D0274), provided by an out-of-network provider on July 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that this provider was in-network. 
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, 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 periapical imaging (D0220 and D0230), a comprehensive oral evaluation (D0150), and bitewings 
(D0274), provided by an out-of-network provider on July 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for 
you. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 home ventilator. Our reviewer says 
that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found 
that there is no documentation of chronic carbon dioxide (CO2) retention with an arterial blood gas (ABG) 
study done while stable. If you do have chronic CO2 retention, you may benefit from BiPAP with average 
volume-assured pressure support (AVAPS) during sleep. However, Medicare does not cover a home ventilator 
when used as BiPAP.  
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bilateral genicular nerve radiofrequency ablation (RFA) 
procedure (64450 x 6, 64640 x 6) provided on April 12, 2022. 
 
You asked the Plan to pay for the genicular RFA. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not medically necessary. The Plan also says the services 
were not billed with the most appropriate code. 
 
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 genicular RFA. Our reviewer says that 
the genicular RFA are not considered medically reasonable and necessary in this case. Our physician reviewer 
found genicular RFA are considered experimental for knee pain. Therefore, the reviewer found that the RFA 
are 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 genicular RFA have not been met. Therefore, we decided that the Plan does 
not have to pay for the bilateral genicular nerve radiofrequency ablation (RFA) procedure (64450 x 6, 64640 x 
6) provided on April 12, 2022.