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

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that this enrollee cannot go without the use of 
the Trilogy, or it could be fatal. The Plan denied your request. The Plan says the rules say ventilators used to 
provide continuous positive airway pressure (CPAP) or bi-level PAP therapy will be denied as not reasonable 
and necessary. The Plan states the requested bi-level positive airway pressure (PAP) therapy with back up rate 
in average volume-assured pressure support (AVAPS) mode is available on E0471 devices (e.g., Phillips 
Dream Station BiPAP with AVAPS or ResMed Stellar 100/150). 
 
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 home ventilator. Our physician 
reviewer found if chronic carbon dioxide (CO2) retention is confirmed with arterial blood gas (ABG) done 
while stable, patient may benefit from bilevel positive airway pressure (BiPAP) with average volume-assured 
pressure support (AVAPS) during sleep. But Medicare does not cover a home ventilator when used as BiPAP.  
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for acupuncture services provided to the enrollee from April 26, 2022, to 
May 18, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says that the claims submitted do not follow Medicare coding guidelines for chronic low 
back pain. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
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 services. Our reviewer says that the 
services at issue in this case were medically reasonable and necessary. Our physician reviewer found that the 
enrollee takes Naproxen, Gabapentin, and Diclofenac. The enrollee has tried chiropractic and massage therapy 
for multi-level arthrosis and foraminal stenosis. The enrollee has a diagnosis of a chronic low back pain, and 
the acupuncture was to treat this diagnosis. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
acupuncture services provided to the enrollee from April 26, 2022, to May 18, 2022.  
 
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 SelectMDx testing for prostate cancer (81479) provided on 
January 6, 2022. 
 
You asked the Plan to pay for the services. You say that this diagnostic test was medically necessary as the 
enrollee was previously found to have elevated prostate specific antigen (PSA). The Plan denied your request. 
The Plan says this test is not a covered screening for prostate cancer. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the SelectMDx testing for prostate cancer (81479) provided on January 6, 2022 is not medically 
reasonable and necessary in the case. The records do not confirm that the enrollee has not had a prior prostate biopsy. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for SelectMDx testing for prostate cancer (81479) provided on January 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 84165 billed for date of service April 5, 
2022. 
 
You asked the Plan to pay for procedure code 84165. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 84165 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 84165 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 84165 billed for date of service April 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the ventilator is not necessary. 
 
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 home ventilator. Our physician 
reviewer found a home ventilator is not medically necessary.  This enrollee has COPD, but there is no 
documentation of chronic carbon dioxide (CO2) retention with arterial blood gas (ABG) done while stable. If 
the enrollee does have chronic CO2 retention, may benefit from bilevel positive airway pressure (BiPAP) with 
average volume-assured pressure support (AVAPS). But Medicare does not cover a home ventilator when used 
as BiPAP. 
 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on 
June 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 3, 2020. 
Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) 
provided on June 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture (D5214) provided by a 
participating provider on July 28, 2022. 
 
You asked the Plan to pay for a mandibular partial denture. You say that you do not understand why this is not 
covered now. The Plan denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
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 a 
mandibular partial denture (D5214) provided by a participating provideron July 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve new lenses for eyeglasses. 
 
You asked the Plan to pre-approve the new lenses. You say that you feel that the new lenses should be covered. 
The Plan denied your request. The Plan says your benefit only covers lenses once every two years. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services only once every two years. 
 
We looked at the file and the Plan's rules. You used this benefit in June 2021, meaning that it is exhausted until 
June 2023. Based on this information, we decided that the Plan's rules for coverage of the new lenses have not 
been met. Therefore, we decided that the Plan does not have to pre-approve new lenses for eyeglasses.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for pain management services provided from 
January 18, 2022, to May 3, 2022. 
 
You asked the Plan to waive the copayments for the pain management services. You say that you were sent to 
this facility by mistake, and you feel you should be reimbursed the full cost. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
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 $200 
copayment for outpatient surgery and a $15 copayment for provider office visits.  
 
You have been asked to pay a $200 copayment for the laminotomy/laminectomy provided on January 18, 2022. 
This item/service falls within the outpatient surgery benefit category. You have also been asked to pay a $15 
copayment for each of the injections on March 8, 2022, and May 3, 2022. This item/service falls within the 
provider office visits benefit category. The file shows that you had initially paid a total of $600 for all of the 
services. You have been reimbursed a total of $370, leaving the copayment total of $230. 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 copayments for pain management services provided from January 18, 2022, to May 
3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Knee-ankle-foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because the 
requested foot orthotics are medically necessary. The Plan denied your request. The Plan says the requested 
foot orthotics are not a covered benefit 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve Knee-
ankle-foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ibrance tablets. 
 
You asked the Plan to pre-approve Ibrance. You say that you are appealing this denial. The Plan denied your 
request. The Plan says this drug is not covered by Medicare Part B and the Plan does not administer the 
enrollee's Medicare Part D prescription drug benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ibrance tablets.  
 
Benefits for Ibrance may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hyperbaric oxygen therapy provided to the enrollee from 
May 26, 2022, to June 17, 2022. 
 
You asked the Plan to pay for the therapy. You say that this was medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet 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 pay for the therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the diagnoses listed on the order form include attention deficit disorder, irritability, and anger, and 
altered mental status. The review indicates that the enrollee did not meet coverage criteria for the 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 the therapy have not been met. Therefore, we decided that the Plan does not 
have to pay for hyperbaric oxygen therapy provided to the enrollee from May 26, 2022, to June 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service July 8, 2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99053 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service July 8, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided August 22, 2022, to August 26, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that these services were medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained for services to be provided out-of-
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 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 physical therapy provided August 22, 2022, to 
August 26, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 24, 2022. 
 
You asked the Plan to pay for dental services. You say that you should not have to pay for the services 
provided. You were out of the country and had to get dental services. The Plan denied your request. The Plan 
says this service is not covered 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. This benefit includes only 
those items and services specifically listed in your Plan contract. You may see any licensed dental provider in 
the U.S. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services 
provided outside of the U.S. are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pay for dental services provided on May 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service May 19, 
2022. 
 
You asked the Plan to pay for procedure code 93010. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 93010 is bundled into payment for code 31500. 
 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, we have confirmed that code 93010 
is a column II code to column I code 31500. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 93010 billed for date of service May 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on May 7, 2022. 
 
You asked the Plan to pay for ambulance response and treatment, no transport (A0998). You say that you were 
having a difficult time breathing, the firemen arrived and helped stabilize you. You also say that then asked you 
if you wanted them to take you for medical assistance, but your daughter arrived and was able to give you a 
ride. The Plan denied your request. The Plan says the service or item in question is not covered under your 
contract under any normal circumstances. 
 
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 May 7, 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 ambulance response and treatment, no transport 
(A0998) provided on May 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper eyelid blepharoplasty. 
 
You asked the Plan to pre-approve the upper eyelid surgery. You say that you need this procedure because your 
vision without it is so poor that you will not be able to drive safely and could lose your license. The Plan denied 
your request. The Plan says the records do not support the medical necessity of this procedure. 
 The Plan follows Medicare rules. Medicare rules say that upper eyelid surgery can be covered when the criteria 
listed in the LCD are met. 
 
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 upper eyelid surgery. Our reviewer 
says that the requested procedure is not supported as medically reasonable and necessary based on the 
documentation submitted. Our physician reviewer found six photographs were submitted. One was a colored 
photograph appear to have been taken and submitted by the patient. The 5 other photographs were 
appropriately taken with positions as per standard but of black and white color, meaning details were not 
clearly visible.  
 
Although visual fields are not required for approval, they were performed and submitted. However, there is no 
clear labeling indicating visual field improvement with lids held or taped up to show such. There is also no 
physician interpretation of the visual fields documented to support the request for blepharoplasty. 
 
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 upper eyelid surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve upper eyelid blepharoplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a filling (D2331), a crown (D2740), and core buildup 
(D2950) for tooth #4 and #6 provided on January 5, 2022, and January 12, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like the Plan to reimburse you 
the amount you paid the provider. The Plan denied your request. The Plan says you are responsible for any 
charged amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
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. 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for a filling (D2331), a crown (D2740), and core 
buildup (D2950) for tooth #4 and #6 provided on January 5, 2022, and January 12, 2022.