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

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional routine transportation trips. You say that you are on dialysis 
and need the requested trips. You say that you cannot afford the cost of this needed transportation on your own. 
The Plan denied your request. The Plan says the enrollee's benefits only cover 20 one-way routine 
transportation trips per plan year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way routine transportation trips per year.  
 We looked at your request, the records in the case file, and the rules. The records show that the Plan has 
covered 20 one-way routine transportation trips in the 2022 calendar year. Based on this information, we 
decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, 
we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panel of genetic tests. 
 
You asked the Plan to pre-approve a panel of genetic tests. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 a panel of genetic tests. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found it was not clear from the documentation how this testing would lead to a significant 
improvement in treatment and overall outcome for you compared to standard testing options. Therefore, 
without sufficient support made for this request, the 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 a panel of genetic tests have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a panel of genetic tests.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endovenous ablation therapy of an incompetent vein. 
 
You asked the Plan to pre-approve an endovenous ablation therapy of an incompetent vein. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that treatment of varicose veins are covered when specific 
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 an endovenous ablation therapy of an 
incompetent vein. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found it is not documented that you are having lifestyle limiting symptoms due to this and is not documented 
that you have been regularly using compression stockings. Therefore, the documentation does not support the 
medical necessity of additional procedures. 
 
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 endovenous ablation therapy of an incompetent vein have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an endovenous ablation therapy of an 
incompetent vein.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen. 
 
You asked the Plan to pre-approve a CT scan. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested CT scan is not medically necessary. 
 
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 scan. Our reviewer says that the 
documentation does not support that the requested CT scan is medically reasonable or necessary. Our physician 
reviewer found you have no abdominal pain. The history and physical examination do not document any 
abdominal symptoms or positive physical findings with respect to the abdomen.  Since apparently there is 
concern of possible ascites, ultrasound is the first test which may be used to rule out or rule in ascites. No 
sonogram report is in the records. Therefore, you do not meet criteria for the requested CT scan. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomography (CT) scan of the abdomen.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a subcutaneous cardiac rhythm monitor 
(implanted loop recorder). 
 
You asked the Plan to pre-approve implanted loop recorder. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve implanted loop recorder. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided to suggest a history of unexplained syncope, 
cryptogenic stroke, or any other apparent indication for an implanted loop recorder.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implanted loop recorder have not been met. Therefore, we decided that the Plan 
does not have to pre-approve use of a subcutaneous cardiac rhythm monitor (implanted loop recorder).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement calf pads (E0995). 
 
You asked the Plan to pre-approve the pads. You say that this unit is upgradeable to accommodate the 
progression of her disease. The Plan denied your request. The Plan says this replacement code should not be 
unbundled, and cannot be provided on initial issue. 
 
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 E0995 is "Wheelchair accessory, calf rest/pad, 
replacement only, each." 
 
We find that accessory code E0995 is not supported in the medical record. Specifically, this is a column II code 
to the main wheelchair code K0849. It should not be requested separately. Additionally, the code is for a 
replacement accessory, and should not be requested upon the initial issue of the wheelchair. Based on this information, we decided that Medicare rules for coverage of the pads have not been met. Therefore, we decided 
that the Plan does not have to pre-approve replacement calf pads (E0995).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 30, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, fluorescence in-situ hybridization (FISH) testing, was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that 
the Plan does not have to pay for the laboratory services rendered on August 30, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the group 3 power wheelchair replacement (K0861), with added 
attendant control (E2331), power elevating leg rest (E1012), push handles (K0108), electronic connection 
(E2311), expandable controller (E2377), and harness (E2313). 
 
You asked the Plan to pre-approve the replacement wheelchair base with added features. You say that the items 
are medically necessary. The Plan denied your request. The Plan says that the items are not medically 
necessary. 
 
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 the replacement wheelchair base with 
added features. Our reviewer says that the requested items are considered medically reasonable and necessary 
in this case. Our physician reviewer found the clinical documentation demonstrates need for additional features 
and website states that although line is being manufactured additional features are not available. 
 
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 replacement wheelchair base with added features have been met. Therefore, 
we decided that the Plan has to pre-approve the group 3 power wheelchair replacement (K0861), with added 
attendant control (E2331), power elevating leg rest (E1012), push handles (K0108), electronic connection 
(E2311), expandable controller (E2377), and harness (E2313).  
 
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 waive the copayment for the ophthalmology visit you had on January 
13, 2022. 
 
You asked the Plan to waive the copayment for the ophthalmology visit. You say that you scheduled this as a 
routine visit, so there should be no copayment. The Plan denied your request. The Plan says you had a medical 
eye visit, so you were charged this copayment 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 $30 
copayment per visit for exams to diagnose and treat diseases and conditions of the eye.  
 
You have been asked to pay a $30 copayment per visit for the ophthalmology visit. Records show that this was 
not a routine eye visit.  Rather, the records show that this was a 6-month check due to complaints of dry eye.  
You were evaluated to eye itchiness and irritation.  In addition, you were also evaluated for a small bump on 
your upper eyelid that causes irritation. These services are not part of a routine eye exam, which is why this 
visit was appropriately coded as a medical eye exam for which a copayment applies. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the ophthalmology visit you had on January 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea (J0178). 
 
You asked the Plan to pre-approve Eylea. The Plan denied your request. The Plan says the off-label use of this 
drug for the enrollee's condition is not medically accepted per Medicare rules and is not covered based on 
available information. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Eylea. Our reviewer says that the 
elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. Our 
physician reviewer found the record indicates that the enrollee has a diagnosis of unspecified retinal 
neovascularization. Our reviewer found that the Food and Drug Administration has not stated that the requested 
drug is indicated for the enrollee's condition. Our physician reviewer also found that the Medicare approved 
drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea (J0178).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve MRI. You say that this MRI is medically necessary. The Plan denied your 
request. The Plan says the requested MRI is not medically necessary. 
 
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 MRI. Our reviewer says that the 
documentation does not support that the requested MRI is medically reasonable or necessary. Our physician 
reviewer found the enrollee has 10-year history of low back pain. The pain sometimes radiates to the legs. 
Neurology exam is normal with no abnormal reflex, weakness, etc. The notes state that physical therapy has 
been provided in the past but there is no documentation of same within the last six months. The medical 
necessity of MRI of the lumbar spine without a trial of six weeks of monitored PT has not been established in 
the records provided. Therefore, the enrollee does not meet criteria for the requested 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 MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 12, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 82656 (1 Unit) remains not supported 
 
The Plan must follow Medicare rules. Medicare rules say that 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 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 laboratory services provided to the enrollee on August 12, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the head. 
 
You asked the Plan to pre-approve an MRI of the head. You say that the medical records provided support the 
need for the requested MRI. The Plan denied your request. The Plan says that they did not receive records 
showing that the enrollee has been diagnosed with dementia. 
 
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 an MRI of the head. Our reviewer says 
that the criteria for coverage have been met. Our physician reviewer found the enrollee in this case is suspected 
of possibly having dementia (or some form of dementia). The generally accepted standard of practice/care in 
the evaluation of dementia, is to generally perform a neuro-imaging study as part of the initial evaluation to 
rule in/out a structural process as a cause for memory impairment. Imaging studies can also provide other 
clinical suggestions as to the etiology of symptoms. In as much it can be adjudged that the request would be 
considered to be reasonable and necessary for this enrollee. 
 
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 MRI of the head have been met. Therefore, we decided that the Plan has to 
pre-approve magnetic resonance imaging (MRI) of the head.  
 
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 waive the copayments for for the cleaning (code D1110), the oral 
evaluation (code D0120), and the oral/facial photographic image (D0350) you received on January 9, 2022. 
 
You asked the Plan to waive the copayments for for the cleaning, the oral evaluation, and the oral/facial 
photographic image. You say that you do not think it is fair that you have to pay a $15 copayment per service 
because you have healthy teeth. The Plan denied your request. The Plan says you were charged three 
copayments 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 $15 
copayment per service during the visit for dental services.  
 
Records show that you had three separate and distinct dental services and you were charged three separate copayments.  Your contract says you pay a $15 copayment per service.  Because the allowed amount for one of 
the services was less than this $15 copayment ($13.59), you are only being charged that amount for that 
individual service.  These copayments apply regardless of the health of your teeth. 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 copayments for for the cleaning (code D1110), the oral evaluation (code D0120), and the 
oral/facial photographic image (D0350) you received on January 9, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve dental services. 
 
You asked the Plan to pre-approve dental services. You say that the enrollee's mouth has deteriorated, causing 
more teeth loss and bone loss. The enrollee cannot eat and function well. The Plan denied your request. The 
Plan says that the requested dental services are not reasonable and medically necessary. 
 
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. Please note, the records submitted by the enrollee are not sufficient. We need 
official medical records identifying information on them. Therefore, we decided that the Plan has to pre-
approve dental 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported porcelain fused to metal crown 
(D6060) for teeth #22, #23, #26, and #27, and prefabricated abutment (D6056) for teeth #23, #23, #26, and #27 
to be provided by a network provider. 
 
You asked the Plan to pre-approve abutment supported porcelain fused to metal crown (D6060) for teeth #22, 
#23, #26, and #27, and prefabricated abutment (D6056) for teeth #23, #23, #26, and #27. You say that the 
services are medically necessary. The Plan denied your request. The Plan says the services are not covered 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested abutment supported 
porcelain fused to metal crown (D6060) for teeth #22, #23, #26, and #27, and prefabricated abutment (D6056) 
for teeth #23, #23, #26, and #27 are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pre-approve abutment supported porcelain fused to metal crown (D6060) for teeth #22, 
#23, #26, and #27, and prefabricated abutment (D6056) for teeth #23, #23, #26, and #27 to be provided by a 
network provider.