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

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that unproven and not medically necessary procedures are not covered 
by Medicare due to insufficient evidence of efficacy. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The vertiflex device 
is experimental. More research is needed. Our physician reviewer found that the enrollee's condition does not 
meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex Superion device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) and core buildup, including any pins 
when required (D2950) provided on December 27, 2021. 
 
You asked the Plan to pay for the crown and core buildup. You say that you were told that the Plan paid 50% 
for fillings and 30% for crowns, but the Plan only paid $139.00. The Plan denied your request. The Plan says 
these services are not covered expenses under your dental plan. The Plan also says that neither you nor the 
provider contacted the Plan to verify 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
(D2740) and core buildup, including any pins when required (D2950) provided on December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), periodic oral 
evaluation (D0120), and prophylaxis (D1110) provided on December 22, 2021. 
 
You asked the Plan to pay for the first intraoral periapical x-ray, periodic oral evaluation, and prophylaxis. You 
say that exams and cleanings are supposed to be paid for by the Plan. You also say that you would like to be 
reimbursed for these services. The Plan denied your request. The Plan says the first intraoral periapical x-ray is 
not a benefit under the dental plan. The Plan also says that periodic oral evaluation and prophylaxis are each 
allowed once per calendar year. 
 
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, first intraoral periapical x-ray (D0220) 
is not among those covered under this benefit. The contract says that you are limited to one oral examination 
per calendar year, and one routine cleaning per calendar year. The record shows that you received an oral exam 
and cleaning on June 16, 2021 and your oral examination and routine cleaning benefits have been exhausted. 
Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), 
periodic oral evaluation (D0120), and prophylaxis (D1110) provided on December 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis and accessories. 
 
You asked the Plan to pre-approve knee orthosis and accessories. You say that this equipment is medically 
necessary. The Plan denied your request. The Plan says the criteria of coverage of the requested equipment 
have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the knee orthoses are covered for a beneficiary who is 
ambulatory and has knee instability. Knee instability must be documented by examination of the beneficiary 
and objective description of joint laxity. 
 
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 knee orthosis and accessories. Our 
reviewer says that the requested orthosis is not medically necessary and reasonable. Our physician reviewer 
found the member is a 65-year-old female with a medical history including chronic knee pain. In this case, the member has not had recent surgery or a recent injury. The documentation does not support that the joint is 
unstable or that there is joint laxity. The requested knee orthosis is not medically 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 knee orthosis and accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a knee orthosis and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on December 
17, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation. You say that based on your policy, you are allowed 
two mouth evaluation per year. You also say that one was not a full mouth evaluation, but a problem focused 
evaluation of 1 tooth because the crown broke off and you needed it fixed. The Plan denied your request. The 
Plan says this service exceeds the frequency limitations under your 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, you are limited to two routine 
cleanings annually. The record shows that you received a problem focused limited oral evaluation (D0140) on 
April 8, 2021, and a periodic oral evaluation (D0120) on June 16, 2021, and your routine cleanings benefit has 
been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation 
(D0120) provided on December 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the 
enrollee does not meet the coverage criteria. 
 
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 does not indicate that the uses insulin with at 
least three daily injections or requires frequent self-adjustment of insulin dosage based on the blood glucose 
testing results. 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 continuous glucose monitor.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 there is no evidence that the enrollee requires services that are not currently available. 
The enrollee can remain at the current facility for the time being until treatment is completed and transfer to a 
lower level of care is more appropriate.  
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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the blepharoplasty of the lower eyelids (15820), a 
blepharoplasty of the upper eyelids (15822), a rhytidectomy of the cheek, chin, and neck (15828), a forehead 
reduction (21138), augmentation of the cheek bone (21270), and a lip repair (40650). 
 
You asked the Plan to pre-approve the Facial Feminization Surgery. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the requested service is cosmetic. It will not repair a 
recent accidental injury or improve the function of an abnormal body part. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Facial Feminization Surgery have not been met.  Therefore, we decided that the Plan does not have to pre-approve the blepharoplasty of the lower eyelids 
(15820), a blepharoplasty of the upper eyelids (15822), a rhytidectomy of the cheek, chin, and neck (15828), a 
forehead reduction (21138), augmentation of the cheek bone (21270), and a lip repair (40650).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the item is medically necessary. 
The Plan denied your request. The Plan says total electric hospital beds are not covered because the height 
adjustment feature is a convenience feature. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing services (G0300, G0299, G0155). 
 
You asked the Plan to pre-approve the skilled nursing services. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not medically necessary. 
 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 the skilled nursing services. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there are no 
documented skilled nursing needs. 
 
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 services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the skilled nursing services (G0300, G0299, G0155).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve human amniotic membrane grafts and amniotic fluid 
injections. 
 
You asked the Plan to pre-approve human amniotic membrane grafts and amniotic fluid injections. The Plan 
denied your request. The Plan says the request is denied as not reasonable and 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 human amniotic membrane grafts and 
amniotic fluid injections. Our reviewer says that the requested human amniotic membrane grafts and amniotic 
fluid injections are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the Plan covers Apligraf or Oasis Wound Matrix for this clinical situation of having chronic venous 
insufficiency wounds which have failed conservative therapies, however, there was no statement suggesting the 
covered graft materials would not be as effective for the enrollees needs. Therefore, without sufficient support 
made for this request, the Human Amniotic Membrane Grafts and Amniotic Fluid Injections 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 human amniotic membrane grafts and amniotic fluid injections have not been 
met. Therefore, we decided that the Plan does not have to pre-approve human amniotic membrane grafts and 
amniotic fluid injections.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the prostate. 
 
You asked the Plan to pre-approve a CT scan of the prostate. The Plan denied your request. The Plan says that 
A study similar to the one requested has already been approved for you. We need results of the prior approved 
study that show the need for repeat imaging, or your doctor must confirm that the prior approved study was not 
performed. 
 
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 of the prostate. Our reviewer 
says that a CT scan of the prostate is medically necessary. Our physician reviewer found that a follow-up CT of 
the chest for multiple pulmonary nodules, presumably metastatic up to 1.7 cm in diameter, seen on a CT of 
August 31, 2021 is reasonable at 8 months in order to assess treatment options.   
 
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 of the prostate have been met. Therefore, we decided that the Plan 
has to pre-approve a CT scan of the prostate.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99222) provided on November 21, 2021. 
 You asked the Plan to pay for initial hospital care. You say that these services were provided in good faith and 
were medically necessary. The Plan denied your request. The Plan says this claim was billed without a valid 
Place of Service (POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate POS code. 
 
We find that CPT code 99222 is not supported in this case. Specifically, this claim was billed without a valid 
POS code. Based on this information, we decided that Medicare rules for coverage of initial hospital care have 
not been met. Therefore, we decided that the Plan does not have to pay for initial hospital care (99222) 
provided on November 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted molecular pathology procedure (81479) 
Methylenetetrahydrofolate Reductase (MTHFR) Thermolabile Variant, DNA Analysis (81291) provided 
August 30, 2021.  
You asked the Plan to pay for GeneSight psychotropic test. You say that you ask for reconsideration of the 
original determination and cover the cost of this test at an in-network benefit level. The Plan denied your 
request. The Plan says the records do not show that the enrollee meets the 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 pay for GeneSight psychotropic test. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a 59-year-old male with major depression, moderate, recurrent. A 
request was made for a GeneSight psychotropic test (including MTHFR). However, the MTHFR was not 
performed and should not be paid for that reason. Also, there was no support provided from clinical 
documentation describing current medical therapy or the intended treatment changes as required. Therefore, 
LCD criteria was not 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 GeneSight psychotropic test have not been met. Therefore, we decided that the 
Plan does not have to pay for unlisted molecular pathology procedure (81479) Methylenetetrahydrofolate 
Reductase (MTHFR) Thermolabile Variant, DNA Analysis (81291) provided August 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on August 27, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the surgery services. You say that the enrollee never informed you that they were 
enrolled in Medicare Risk Management insurance. The Plan denied your request. The Plan says the rendering 
provider is an out-of-network 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 surgery services provided on August 27, 2021, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are not 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 you do not use insulin three or 
more times per day or an insulin pump. Based on this information, we decided that Medicare rules for coverage 
of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
continuous glucose monitor (CGM) supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 4, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 lab 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 lab services provided on August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 5, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 lab 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 lab services provided on August 5, 2021.