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

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
April 25, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the physician only provided medically 
necessary services to the enrollee in good faith. The Plan denied your request. The Plan says the enrollees 
claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on 
the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the 
providers responsibility to verify the enrollees coverage before rendering services and to know proper billing 
procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
April 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an InSpace biodegradable subacromial spacer. 
 
You asked the Plan to pre-approve an InSpace biodegradable subacromial spacer. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an InSpace biodegradable subacromial 
spacer. 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 compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
InSpace biodegradable subacromial spacer, in this case, 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 an InSpace biodegradable subacromial spacer have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an InSpace biodegradable subacromial spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingivectomy or gingivoplasty to allow access for 
restorative procedure, per tooth (D4212). 
 
You asked the Plan to pre-approve the gingivectomy or gingivoplasty to allow access for restorative procedure, 
per tooth (D4212). You say that this service is medically necessary. The Plan denied your request. The Plan 
says this service is not covered under the benefit package. 
 
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 pre-approve 
gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth (D4212).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve FoundationOne CDx testing (0037U). 
 
You asked the Plan to pre-approve FoundationOne CDx testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says that the request does not meet criteria because there are 
no clinical notes indicating that the enrollee has either recurrent, relapsed, refractory, metastatic, or advanced 
stage III or IV cancer, and not been previously tested with the same test using NGS for the same cancer genetic 
content, and decided to seek further cancer treatment. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare covers this NGS testing when the enrollee 
has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer and has not been 
previously tested with the same test using NGS for the same cancer genetic content. 
 
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 FoundationOne CDx testing. Our 
reviewer says that this testing is medically necessary. Our physician reviewer found that malignant melanotic 
nerve sheath tumors are heterogenous tumors that often follow an aggressive course. Due to the rarity no clear 
guidelines exist to guide decision making. Molecular profiling is recommended to both help classify the tumor 
as well as guide therapy decision making. The service is reasonable and 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 FoundationOne CDx testing have been met. Therefore, we decided that the Plan 
has to pre-approve FoundationOne CDx testing (0037U).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cala Trio device and supplies. 
 
You asked the Plan to pre-approve Cala Trio device and supplies. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that electric nerve stimulation is only covered for certain 
indications. 
 
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 Cala Trio device and supplies. Our 
reviewer says that the documentation does not support that the requested device is medically reasonable or 
necessary. Our physician reviewer found the enrollee has a diagnosis of essential tremor. This would fall within 
the scope of being a motor disorder. However, the NCD states while electric nerve stimulation has been 
employed to control chronic intractable pain for some time, its use in the treatment of motor function disorders, 
such as multiple sclerosis, is a recent innovation, and the medical effectiveness of such therapy has not been 
verified by scientifically controlled studies. Therefore, the enrollee does not meet criteria for the requested 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cala Trio device and supplies have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Cala Trio device and supplies.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an expandable controller with harness and electronic connection. 
 
You asked the Plan to pre-approve the wheelchair accessories. The Plan denied your request. The Plan says that 
these wheelchair accessories are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a power wheelchair electrical connection, expandable 
controller, and harness, are covered for the indications established in the applicable LCA. 
 
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 wheelchair accessories. Our 
reviewer says that the requested expandable controller with harness and electronic connection are medically 
reasonable and necessary in this case. Our physician reviewer found that the enrollee is non-ambulatory and 
requires a power wheelchair for mobility and performing her basic daily activities. She cannot perform pressure 
relief independently due to weakness and spasticity and requires a power wheelchair with power tilt and recline 
for adequate pressure relief and positioning. She also requires power elevating leg rests for positioning and her 
lower extremity spasticity and contracture. The complexity of her seating and positioning needs necessitates a 
more complex group 3 power wheelchair base. The expandable controller with harness and electronic 
connection are necessary to operate the group 3 power wheelchair base and the power tilt and recline and 
power elevating leg rests via a joystick. 
 
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 wheelchair accessories have been met. Therefore, we decided that the Plan 
has to pre-approve an expandable controller with harness and electronic connection.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81162) provided on July 7, 2022. 
 
You asked the Plan to pay for genetic testing. You say that the genetic testing at issue was 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. The rules say that for coverage eligibility, the enrollee must meet the 
criteria listed in the Medicare rules section of this letter. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Specifically, the available medical records do not support that 
the enrollee has a cancer diagnosis. Therefore, we decided that the Plan does not have to pay for genetic testing 
(81162) provided on July 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve a CGM and related supplies. You say that the requested items are a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage of CGMs and related 
supplies 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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and 
related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) and related supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power operated vehicle, group 2 standard, patient 
weight capacity up to and including 300 pounds (K0806). 
 
You asked the Plan to pre-approve the Group 2 power operated vehicle. You say that you use oxygen and has 
to take frequent breaks when walking for any distance. The power chair would be helpful when going to doctor 
appointments, grocery store, church and the park The Plan denied your request. The Plan says Under Medicare 
guidelines, this request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that you do not have a mobility deficit that impairs your participation in mobility related 
activities of daily living and it is unclear if this request is intended for use inside the home as the request is for a 
Group 2 POV with added capabilities that are not needed for use in the home. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the power operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds (K0806).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the portable gaseous oxygen system rental (E0431) and 
oxygen concentrator (E1390). 
 
You asked the Plan to pre-approve the portable gaseous oxygen system rental and oxygen concentrator. You 
say that the item should be covered. The Plan denied your request. The Plan says the vendor is required to 
provide contents and services of oxygen equipment for month 37-60. 
 
The Plan must follow Medicare rules. Medicare rules say that after 36 months, the vendor is required to 
provide contents and services of oxygen equipment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the portable gaseous oxygen system rental and oxygen concentrator have not been met. 
Specifically, the 36-month rental period has been exhausted.  
 
 
 
  
 
Therefore, we decided that the Plan does not have to pre-approve the portable gaseous oxygen system rental 
(E0431) and oxygen concentrator (E1390).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing this denial. The Plan 
denied your request. The Plan says the denial of LTACH services is correct. 
 
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 requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 LTACH services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
June 8, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the service should be covered. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on June 
8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (76870, 93976) provided on July 30, 
2021. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on September 8, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the radiology services have not been met. 
Therefore, we decided that the Plan does not have to pay for radiology services (76870, 93976) provided on 
July 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and 
appliances (E0667 and E0656). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested device. 
 
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 the enrollee 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) and appliances (E0667 and E0656).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radial fracture treatment provided on September 13, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the radial fracture treatment. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the provider is out-of-network and authorization was not obtained 
prior to 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 provider at issue in this case is not a network provider with the Plan. 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 the radial fracture treatment. Our reviewer says that the records do not indicate 
that the care provided was medically necessary. Our physician reviewer found the enrollee was previously 
treated and discharged from the hospital for a distal radial fracture. It would have been medically reasonable to 
delay the services until when enrollee returned to his/her service area. 
 
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 radial fracture treatment have not been met.  
 
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 pay for the radial fracture treatment. Therefore, we decided that the 
Plan does not have to pay for a radial fracture treatment provided on September 13, 2022, by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Dexcom G6 Sensor continuous glucose monitor (CGM). 
 
You asked the Plan to pay for a CGM. The Plan denied your request. The Plan says the coverage criteria are 
not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for a CGM. Our reviewer says that the requested 
CGM is not medically reasonable and necessary. Our physician reviewer found that the provided medical 
records do not document the enrollee is insulin treated with three or more daily administrations of insulin or a 
Medicare-covered continuous subcutaneous insulin infusion pump. The provided medical records do not 
document the enrollee's insulin treatment regimen requires frequent adjustment by the enrollee on the basis of BGM or CGM testing results. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have to 
pay for a Dexcom G6 Sensor continuous glucose monitor (CGM).