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

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and related accessories. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is at risk for falls and 
injury. The Plan denied your request. The Plan says the request exceeds the enrollee's needs. 
 
The Plan must follow Medicare rules. Medicare rules say that power mobility devices are only covered under 
certain medical indications. The file shows that a group 3 power wheelchair with tilt and recline was requested. We looked at the file and 
Medicare rules. The records do not show that the enrollee is at high risk for a pressure ulcer, uses 
catheterization for bladder management, or has a need for increased tone or spasticity. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 3 power wheelchair and related accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two crowns (D2740 x2) and core buildup, including any 
pins when required (D2950) provided on February 22, 2022, and March 14, 2022. 
 
You asked the Plan to pay for the crowns and core buildup. You say that the Plan sent the dentist the wrong 
policy for you. You also say that you proceeded with the dental care not knowing the wrong policy was sent 
and crowns would not be covered. The Plan denied your request. The Plan says these services are not covered 
expenses under your dental plan. The Plan also says that you did not contact the Plan prior to the date of 
service to verify benefits and provider eligibility. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two 
crowns (D2740 x2) and core buildup, including any pins when required (D2950) provided on February 22, 
2022, and March 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing service (V5299) provided on February 16, 2022 
by a non-network provider. 
 
You asked the Plan to pay for the hearing service. The Plan denied your request. The Plan says all non-
Medicare covered hearing aid services must be provided by the network hearing aid provider. The Plan also 
says that prior to this visit, you received a referral to go to the Plan's contracted provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the service is performed by the network hearing aid provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing service have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing service (V5299) provided on February 16, 2022 by a non-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first 
intraoral periapical x-ray (D0220), periodontal maintenance (D4910), gingival irrigation (D4921), and 
adjunctive procedure (D9999) provided from March 22, 2021, to May 21, 2021 by an out-of-network (OON) 
provider.  
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, 
periodontal maintenance, gingival irrigation, and adjunctive procedure. You say that you would like to appeal 
these services. The Plan denied your request. The Plan says the provider who performed these services is not in 
the Plan's network. The Plan also says while you are a member of the Plan, you must use network providers to 
receive dental services. 
 
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 items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), periodontal maintenance 
(D4910), gingival irrigation (D4921), and adjunctive procedure (D9999) provided from March 22, 2021, to 
May 21, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE) with doppler 
(93306). 
 
You asked the Plan to pre-approve a TTE. You say that the enrollee's previous imaging showed an ejection 
fracture of 50-55%. This imaging is necessary for further evaluation. The Plan denied your request. The Plan 
says repeat imaging is not medically necessary at this time. The enrollee has had no change in clinical status 
related to the functioning of the heart and there are no new signs and symptoms to investigate. 
 
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 TTE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a previous TTE was performed in October 2021. Clinical guidelines do not support carrying out 
a repeat TTE in this setting. There is not supportive evidence for the medical necessity of a follow-up 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 not been met. Therefore, we decided that the Plan does not have to 
pre-approve a transthoracic echocardiography (TTE) with doppler (93306).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services and the outpatient clinic visit provided 
on February 2, 2022, and March 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services and the outpatient clinic visit. You say that you were 
unaware that the provider was an OON provider. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physician services and the outpatient clinic 
visit provided on February 2, 2022, and March 9, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system, expandable controller, 
harness for upgrade to expandable controller, and electronic connection between wheelchair controller and two 
or more power seating system motors. 
 
You asked the Plan to pre-approve a power seat elevation system, expandable controller, harness for upgrade to 
expandable controller, and electronic connection between wheelchair controller and two or more power seating 
system motors. You say that you would like the plan to reconsider their denial. The Plan denied your request. 
The Plan says the enrollee does not meet criteria for the requested items. 
 
The Plan must follow Medicare rules. Medicare rules say that power seat elevation systems are not a covered 
benefit. Medicare rules also say that power wheelchair accessories are only covered for certain indications. 
 
We looked at the file and Medicare rules. The requested power seat elevation system is not covered. While the 
documentation shows that there are three requested power options (tilt, recline, and elevating leg rests), there is 
no medical need to control these power options through the joystick. The documentation shows that the 
enrollee can feed, brush teeth, and brush hair independently. The enrollees upper limb strength and function 
are adequate for the enrollee to be able to control the power options using their own switches which are 
included in the allowance of the power options. 
 
Based on this information, we decided that Medicare rules for coverage of a power seat elevation system, 
expandable controller, harness for upgrade to expandable controller, and electronic connection between 
wheelchair controller and two or more power seating system motors have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power seat elevation system, expandable controller, harness for 
upgrade to expandable controller, and electronic connection between wheelchair controller and two or more 
power seating system motors.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a 
spinal puncture, therapeutic, for drainage of cerebrospinal fluid and will need inpatient admission after surgery. 
The Plan denied your request. The Plan says the services at issue are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee is approved for a spinal puncture, therapeutic, for drainage of 
cerebrospinal fluid. The record does not document that the treating physician has a reasonable expectation of a 
length of stay spanning 2 or more midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the remaining 10 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve PT visits. You say that you disagree with the denial for additional physical 
therapy visits. The Plan denied your request. The Plan says the remaining 10 physical therapy visits are not 
medically necessary, and a home exercise program should help you reach your goals. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 PT visits. Our reviewer says that the 
services are not medically necessary. Our reviewer found that the skilled services are not necessary to restore 
or maintain function or to prevent or slow deterioration of the enrollee's condition. Our physician reviewer 
found the enrollee can begin to transition to an independent home exercise 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 PT visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the remaining 10 physical therapy (PT) visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 14, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this 
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing provided on December 14, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the skilled nursing facility (SNF) services. You say that you are requesting 
reconsideration stating that you do not understand how you can be medically cleared to go, nor has the original 
cause (back pain) of all this been resolved. The Plan denied your request. The Plan says the skilled nursing 
facility (SNF) services you and/or your provider are requesting do not meet the requirements for approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 the skilled nursing facility (SNF) 
services. Our reviewer says that the service is not medically necessary. Our physician reviewer found based on 
the medical records provided there is no documentation that the patient requires the services on an inpatient 
basis, only in a skilled nursing facility setting. Records do not document that services in the long-term care 
facility on a part time basis are not appropriate in this case. 
 
 
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 skilled nursing facility (SNF) services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retractable headrest for a wheelchair (A9270, E1028). 
 
You asked the Plan to pre-approve the retractable headrest. You say that the headrest 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 accessories that are swingaway, retractable, or 
removable hardware is considered appropriate when the component or accessory needs to be moved out of the 
way so that the patient can perform a slide transfer to a chair or bed. 
 
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 retractable headrest. Our reviewer 
says that this feature is not medically necessary. Our physician reviewer found the documentation doesnt 
support that the member has a need for a retractable headrest. This accessory wouldn't allow the member to 
transfer using a slide board. 
 
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 retractable headrest have not been met.  
 
 
 
 Therefore, we decided that the Plan does not have to pre-approve a retractable headrest for a wheelchair 
(A9270, E1028).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (D4381), four 
gingival irrigations (D4921 x4), and two drugs or medicaments dispensed in the office for home use (D9630 
x2) provided on February 16, 2022, and February 17, 2022. 
 
You asked the Plan to pay for the localized delivery of antimicrobial agents, gingival irrigations, and drugs or 
medicaments. You say that you were told that the Plan would cover some of the cost of these services and you 
would have to pay the remainder. You also say that the Plan representative you spoke with advised the deep 
cleaning was fully covered. The Plan denied your request. The Plan says these services are not covered 
expenses under your dental plan. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
localized delivery of antimicrobial agents (D4381), four gingival irrigations (D4921 x4), and two drugs or 
medicaments dispensed in the office for home use (D9630 x2) provided on February 16, 2022, and February 
17, 2022.  
 
Your complaint about being given false information from the provider is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on February 18, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that the provider is in-network and he 
performed routine chiropractic care. You say that you were charged a $30 copayment and the denial of 
coverage should be reversed. The Plan denied your request. The Plan says the chiropractic manipulative 
treatment will be covered. The Plan also says the physical therapy services remain denied as the only covered 
chiropractic service is manual manipulation of the spine to correct subluxation. 
 
  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 physical therapy services provided on February 18, 2022.
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 the Vertiflex procedure. You say that this procedure is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is 
experimental/investigational. 
 
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 the Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed before coverage can be 
approved. 
 
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 Vertiflex procedure have not been met.  
 
 
  
 
Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
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 enrollee's needs cannot be adequately 
cared for in her current condition at any other lower level of care. The Plan denied your request. The Plan says 
the enrollee is receiving appropriate inpatient care at the current hospital and is unstable for transfer. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where she is currently receiving care. 
 
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.