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

 
We decided that the Plan does not have to pay for TissueCypher Barretts esophagus assay (0108U) provided 
on July 5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that your claim for the TissueCypher Barretts 
esophagus test was denied in error and you are requesting it be reprocessed and paid. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 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 TissueCypher Barretts esophagus assay (0108U) 
provided on July 5, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service 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 a Vertiflex procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the Vertiflex device is experimental. More research is needed to demonstrate its safety and 
efficacy. 
 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy (PBT), 45 fractions (77370, 77470, 
77522, G6002). 
 
You asked the Plan to pre-approve proton beam therapy. You say that you have attached an updated list of 69 
references that pertain to the direct support for the utilization of PBT for Prostate Cancer. PBT is the optimal 
choice for the enrollee because it allows you to treat his target volume and spare his surrounding organs at risk 
to a greater degree than with other treatments. The Plan denied your request. The Plan says the request does not 
meet the Medicare or health plan coverage criteria. 
 
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 proton beam therapy. 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 clear evidence that proton beam therapy for prostate cancer offers any 
clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a 
possible advantage of this expensive therapy. Proton therapy for prostate cancer is not experimental, and in fact 
is an accepted treatment approach. To date, there is no compelling data to suggest that proton therapy is 
superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is 
to only offer proton beam therapy on clinical trials, and to not routinely offer it to enrollees. While NCCN 
guideline consider proton therapy a reasonable alternative they do not describe it as being necessary in lieu of 
non-proton-based treatment and are quite explicit in that there is no evidence of its superiority. Notably, 
registry studies are not clinical trials or studies, and have a much less rigorous development process. A tumor 
registry does not address a specific scientific question but rather registers the enrollees clinical and treatment 
information into a database for potential analysis in the future. Nevertheless, it is not specified if a clinical trial 
review was sought or whether this insurer allows for clinical trial exceptions. The decision is unfavorable as the 
LCD criteria has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy (PBT), 45 fractions (77370, 77470, 77522, G6002).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom 6 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you need this CGM. The Plan denied your request. 
The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections, or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom 6 continuous 
glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the routine transportation trip. 
 You asked the Plan to pre-approve the routine transportation. You say that this is an appointment to review 
your magnetic resonance imaging (MRI). You also say that you do not drive or have family or anyone to drive 
you to this appointment to determine if you need surgery. The Plan denied your request. The Plan says there is 
a 50-mile limit per trip. Your requested transportation in each direction has exceeded the mileage limit. 
 
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 routine transportation when it is within the 50-mile limit per trip. 
 
We looked at your request, the records in the case file, and the rules. Your requested transportation has 
exceeded the mileage limit. Based on this information, we decided that the Plans rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve a routine 
transportation trip.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on July 13, 2022. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this service was billed with an invalid place of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code assigned by the 
physician/practitioner for the PC of a diagnostic service shall be the setting in which the beneficiary received 
the TC service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for radiological services provided on July 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on  
July 11, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were not purchased through the Plan's select hearing aid 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 purchased through the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract provides coverage for hearing aids 
only when purchased through the Plans select hearing aid provider. However, the hearing aids in this case 
were ordered through another provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5261) purchased on July 11, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on October 29, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that if you had 
known that calling 911 when you were having serios chest pains would cost you 484, you don't know what you 
would have done.  The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 29, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on October 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on July 3, 2021, to July 8, 
2021. 
 
You asked the Plan to pay for the home health services. You say that we did not send the corrected claim in 
time. You also say that you have provided the medical records for review as the services were a medically 
necessary. The Plan denied your request. The Plan says the claim was not received within the allowed 12 
months from the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the home health services was not filed until October 7, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for home health services provided on July 3, 2021, to July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on February 6, 2023. 
 
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. 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 the office visit (99202) provided on February 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implants and anesthesia. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says this service is not a covered benefit 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. Specifically, implants are covered but the records show the implants 
are to support a denture. Implant supported dentures are not a covered benefit. Additionally, anesthesia is not 
covered in this case because the primary service is not a covered benefit. Therefore, we decided that the Plan 
does not have to pre-approve the implants and anesthesia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is available in-network. 
 
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a wheelchair to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you were admitted for sepsis and a pressure ulcer. Medical problems are stable. 
There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and laboratory services provided on April 11, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and laboratory services. You say that you thought this provider 
was in-network. The Plan denied your request. The Plan says this was not authorized. 
 
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 an office visit and laboratory services provided on 
April 11, 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 positive airway pressure (PAP) supplies (A7035, 
A7036, A4604, A7039, A7045, A7046, A7030, A7031, A7032, A7033, A7038). 
 
You asked the Plan to pre-approve PAP supplies. You say that you disagree with the denial and have submitted 
clinical documents for review. The Plan denied your request. The Plan says you do not meet criteria for 
approval of the PAP supplies. 
 
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 PAP supplies. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found provided records in this case do not document use of the CPAP device for =4 hours per night 
on 70% of nights during a consecutive thirty (30) day period as required by the Local Coverage Determination 
(LCD) Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea L33718. The 
LCD also states: "Accessories used with a PAP device are covered when the coverage criteria for the device are 
met. If the coverage criteria are not met, the accessories 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 PAP supplies have not been met. Therefore, we decided that the Plan does not 
have to pre-approve positive airway pressure (PAP) supplies (A7035, A7036, A4604, A7039, A7045, A7046, 
A7030, A7031, A7032, A7033, A7038).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan provided on September 
22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a CT scan. You say that this is supported in records. The Plan denied your 
request. The Plan says this was not authorized. 
 
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 a computed tomography (CT) scan provided on 
September 22, 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 G6 Dexcom watch glucose monitor. 
 
You asked the Plan to pre-approve the G6 Dexcom watch glucose monitor. You say that you need the watch 
because you are diabetic and do not want to carry a machine around. You also say that if your levels drop while 
sleeping you will be notified with the G6 Dexcom watch. The Plan denied your request. The Plan says there is 
no clinical documentation to support your statements or that current CGM provides the information needed by 
you. 
 
The Plan must follow Medicare rules. Medicare rules say that equipment which the beneficiary owns or is a 
capped rental item may be replaced in cases of loss or irreparable damage.  
 
We looked at the file and Medicare rules. The record does not show that your current CGM has sustained a loss 
or irreparable damage. Your CGM is less than five years old so it is still within its reasonable useful lifetime.  Based on this information, we decided that Medicare rules for coverage of the G6 Dexcom watch glucose 
monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a G6 Dexcom 
watch glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298 x 2) purchased on 
October 13, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network 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 purchased through the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract says that hearing aids are covered 
only when purchased through the Plans select hearing aid provider. However, the hearing aids in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5298 x 2) purchased on October 13, 2022.