Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a denture rebase (D5710). 
 
You asked the Plan to pre-approve the dental service. You say that your dentures keep breaking. You also say 
that you need them to be remade. The Plan denied your request. The Plan says denture rebase 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 denture rebase is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
denture rebase (D5710).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator non-invasive interface (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested device is medically necessary. 
The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
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 service is not medically necessary. Our physician reviewer found the limited documentation provided 
does not support the plan's denial of the portable ventilator (E0466). E0466 when used to provide CPAP or bi-
level PAP (with or without backup rate) therapy, regardless of the underlying medical condition, shall not be 
paid in the FSS payment category. A ventilator is not eligible for reimbursement for any of the conditions 
described in the RAD LCD even though the ventilator equipment may have the capability of operating in a bi-
level PAP mode. Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions 
described in this RAD policy will be denied as not reasonable and 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator non-invasive interface (E0466).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by the requested provider. 
 
You asked the Plan to pre-approve an office visit to be provided by the requested provider. You say that you 
have been seeing this provider for 3 + years, and to lose your behavioral health services would not be good 
for your mental health. The Plan denied your request. The Plan says this provider is not a Plan network 
provider or a Medicare qualified provider. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pre-approve an office visit to be provided by the requested provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dietician services (99205, S9470, Z6200, Z6202). 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that the dietician services are 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve dietician services (99205, S9470, Z6200, Z6202).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival flap procedure (D4241) and bone graft for repair 
of peri-implant defect (D6103) provided on December 30, 2021. 
 
You asked the Plan to pay for the gingival flap procedure and bone graft. You say that these procedures were 
done to save the two implants on those teeth. You also say that without the procedure the infection would have 
resulted in the loss of the implants and costly new implants would have to be surgically placed. The Plan 
denied your request. The Plan says these services are not covered benefits 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 
gingival flap procedure (D4241) and bone graft for repair of peri-implant defect (D6103) provided on 
December 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transport of portable X-ray equipment and personnel to the 
enrollee's home or nursing facility (R0070) and related X-ray services provided on October 25, 2021. 
 
You asked the Plan to pay for a transport of portable X-ray equipment and personnel and related X-ray 
services. You say that the requested services were a medical necessity for the enrollee. The Plan denied your 
request. The Plan says rules for payment have not been met. 
 
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 R0070 is "Transportation of portable x-ray equipment 
and personnel to home or nursing home, per trip to facility or location, one patient seen." 
 
We find that the denied services at issue are not supported in the medical records. Specifically, the place of 
service (POS) used on the claim was 11, for an office setting rather than the home or nursing facility.  
 As the portable imaging transportation code was not appropriate for the place of service, the related X-ray 
services themselves cannot be considered appropriate, as they should be provided in the home or nursing 
facility when billed alongside code R0070, not the office (POS 11). Based on this information, we decided that 
Medicare rules for coverage of a transport of portable X-ray equipment and personnel and related X-ray 
services have not been met. Therefore, we decided that the Plan does not have to pay for a transport of portable 
X-ray equipment and personnel to the enrollee's home or nursing facility (R0070) and related X-ray services 
provided on October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve the RFA. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is a lack of adequately designed trials in the peer-reviewed literature concerning 
the use of genicular nerve blocks and radiofrequency ablation as treatments for chronic knee pain. 
 
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 RFA. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and 
not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the 
following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a 
treatment following knee replacement; or as a treatment for individuals who are not candidates for knee 
replacement surgery. The review has determined that the requested genicular nerve radiofrequency ablation of 
the right knee is 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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve genicular nerve radiofrequency ablation (RFA).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography CT scan of 
abdomen and pelvis without contrast on January 20, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you want the plan to pay for the medical 
care. The Plan denied your request. The Plan says  a $115 copayment for Medicare-covered radiological 
diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility (such as 
a radiology center or medical clinic). You pay these amounts until you reach the out-of-pocket maximum. 
 
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 $115 
copayment for in-network CT scans.   
You have been asked to pay a $115 copayment for CT scan. CT scans fall within the health plan contract that 
says that enrollees must pay a $115 copayment for covered services. The provider billed for a CT scan in the 
amount of $5,083.00 and the plan allowed $228.60. Per your benefits, you are responsible for a $115 
copayment for outpatient radiological diagnostic test. 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 
computed tomography CT scan of abdomen and pelvis without contrast on January 20, 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 this provider is the number one neurological clinic in the US. The Plan denied your 
request. The Plan says the services are available in Plan and the member is contractually required to obtain this 
service from network providers. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 home health physical therapy. 
 
You asked the Plan to pre-approve 7 home health physical therapy. 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 must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 7 home health physical therapy. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not 
have documented, ongoing, home health physical therapy needs. The enrollee is functioning at a level 
commiserate with a lower level of care.  As such, the requested, ongoing, home health physical therapy 
services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 7 home health physical therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 7 home health physical therapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stab phlebectomy. 
 
You asked the Plan to pre-approve stab phlebectomy. The Plan denied your request. The Plan says the coverage 
criteria are not met. 
 
The Plan follows Medicare rules. Medicare rules say that the treatments of the tributary veins will be 
considered medically necessary if saphenous reflux is not present or already successfully eliminated, the veins 
are greater than 4mm in diameter and if the patient remains symptomatic after a six-week trial of conservative 
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 stab phlebectomy. Our reviewer says 
that stab phlebectomy is not medically reasonable and necessary in this case. Our physician reviewer found that 
the documentation does not support that all of the coverage criteria, as established by LCD L33575, have been 
met in this case. The documentation does not include failed conservative measures that include weight 
reduction. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of stab phlebectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve stab phlebectomy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a whole body positron emission tomography (PET) 
scan. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare determines that PET NaF-18 PET is nationally non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee has biopsy 
proven prostate cancer and has received treatment for the disease via proton beam radiation. His rising prostate 
specific antigen (PSA) is suspicious for tumor recurrence/residual. He thus qualifies for post therapeutic failure 
imaging. However, the requested NaF-18 PET/CT (computed tomography) is specific for bone. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a whole body positron emission tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this is medically necessary. 
The Plan denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that you had at least four weeks 
of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and 
supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. 
Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical fusion C4-5, C5-6, C6-7 anterior cervical 
discectomy and arthroplasty, coded as 22858, 22551, 22856, 22845, and 22853. 
 
You asked the Plan to pre-approve the surgical procedure. You say that the medical records provided support 
the necessity of the requested services. The Plan denied your request. The Plan says clinical information was 
not received from the provider and medical studies havent proven that three level total disc arthroplasty in the 
cervical spine is helpful for treatment of cervical spinal stenosis/myelopathy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgical procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve cervical fusion C4-5, C5-6, C6-7 anterior cervical discectomy and arthroplasty, coded as 22858, 
22551, 22856, 22845, and 22853.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the requested device. You say that you have COPD with respiratory failure. 
The Plan denied your request. The Plan says Medicare does not cover ventilators for the requested use. 
 
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 requested device. Our physician 
reviewer found that you have a diagnosis of COPD requiring nasal cannula oxygen, as well as recent 
pneumonia. The clinical documentation does not support that BiPAP with back-up rate or volume assured 
pressure support will be ineffective. The provider does not sufficiently support that a ventilator is needed 
instead of this. 
 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 requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultra-lightweight manual wheelchair (K0005). 
 
You asked the Plan to pre-approve an ultra-lightweight manual wheelchair. You say that the enrollee has 
several mobility related disabilities. The Plan denied your request. The Plan says the records show the enrollee 
does not have a specialty evaluation by a wheelchair specialist that indicates that this wheelchair is necessary 
and appropriate. The Plan also says the requested wheelchair does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that an ultra-lightweight manual wheelchair (K0005) is 
covered for a beneficiary if criteria (1) or (2) is met and (3) and (4) are met. 
 
The file shows that the enrollee is not a full-time manual wheelchair user or needs special adjustments for one 
or more features which cannot be found in another type of manual wheelchair. There is no documentation 
showing the enrollee can safely operate the wheelchair in their home. This means that Medicare rules for 
coverage of a manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-
approve an ultra-lightweight manual wheelchair (K0005).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional non-emergency transportation trips. 
 
You asked the Plan to provide coverage for additional non-emergency transportation trips. The Plan denied 
your request. The Plan says the enrollee has exhausted the established benefit of 24 one-way trips. 
 
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 24 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the enrollee has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide coverage for additional non-emergency transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204), the annual alcohol misuse screening 
(G0442), and the annual depression screening (G0444) rendered by the out-of-network (OON) provider on 
October 29, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 was not a network provider with the Plan at the time the services were rendered. The 
Plan had network providers available who could have provided the services at issue in this appeal. The Plan did 
not pre-approve the services at issue. We found no exception that would require the Plan to pay for these 
services. Therefore, we decided that the Plan does not have to pay for the office visit (99204), the annual 
alcohol misuse screening (G0442), and the annual depression screening (G0444) rendered by the out-of-
network (OON) provider on October 29, 2021.