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

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that you are not able to breathe on your own and 
have frequently dropping oxygen levels. You say that you have been at the hospital for almost a month due to 
the machine not being approved and that you will die in your sleep at home without it. The Plan denied your 
request. The Plan says the requested ventilator was prescribed to help the enrollee's breathing at various times 
of the day because of lung disease. The Plan says that Medicare does not cover ventilators used in this way. 
The Plan says that if advanced capability such as average volume-assured pressure support (AVAPS) 
technology is needed, this is available on respiratory assist devices such as bi-level positive airway pressure 
(BiPAP). 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the record indicates that the 
enrollee has chronic respiratory failure from obstructive sleep apnea and obstructive physiology revealed by 
pulmonary function testing. The provided primary source documentation does not contain sufficient detailed 
information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP 
machine with AVAPS capability. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DME provided on September 14, 2022. 
 
You asked the Plan to pay for DME. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for DME provided on 
September 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) for tooth #31 provided on 
March 1, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied dental service. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because the bone 
replacement graft is not covered by the 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a bone 
replacement graft (D7953) for tooth #31 provided on March 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Supartz. 
 
You asked the Plan to pre-approve Supartz. You say that the enrollee is still having severe functional 
limitations and has not responded to conservative management. The Plan denied your request. The Plan says 
the enrollee does not meet criteria for Supartz. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Supartz. Our reviewer says that the 
enrollee does not meet criteria for use of Supartz. Our physician reviewer found the enrollee has a diagnosis of 
osteoarthritis of the knee and received Supartz injections in October 2022 and January 2023. The Food & Drug 
Administration (FDA) has stated that this drug is indicated for the enrollee's condition. However, the records 
do not establish the medical necessity of the requested drug as prescribed 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 Supartz have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Supartz.
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 enrollee needs constant medical 
oversight and will benefit from both physical therapy and occupational therapy. The Plan denied your request. 
The Plan says the records do not show that it is medically safe for the enrollee to leave the hospital, as it is not 
clear that the enrollee has reached respiratory or cardiac stability. The Plan says that the enrollee continues to 
require high flow oxygen and aggressive respiratory management with a high risk of further decompensation. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving care. All medically necessary care is being provided in the 
current acute care setting. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting. 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the periodontal scaling and root planning (D4341) for tooth 
numbers 25 and 32. We decided that the Plan does not have to pay for the periodontal scaling and root 
planning (D4341) for tooth numbers 1 and 8, and a complete series of x-rays (D0210).  
 
You asked the Plan to pay for the dental services. You say that your provider told you these services would be 
covered under your dental plan. The Plan says that your benefit for the requested items or services has already 
been exhausted. 
 
We decided that the Plan has to pay for the periodontal scaling and root planning (D4341) for tooth 
numbers 25 and 32.  
 
We looked at the case file, and the Plans contractual rules. The record shows on December 10, 2020, you 
received periodontal scaling for tooth numbers 25 and 32. The plan denied payment stating documentation 
does not support this service, so your benefit for this quadrant were not exhausted. Therefore, we decided that 
the Plan has to pay for the periodontal scaling and root planning (D4341) for tooth numbers 25 and 32.  
 
We also decided that the Plan does not have to pay for the periodontal scaling and root planning (D4341) 
for tooth numbers 1 and 8, and a complete series of x-rays (D0210). 
 
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 benefits for the requested items or services was exhausted on dates of service December 10, 2020, 
and November 24, 2020. Therefore, we decided that the Plan does not have to pay for the periodontal scaling 
and root planning (D4341) for tooth numbers 1 and 8, and a complete series of x-rays (D0210) provided on 
May 20, 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is currently on antibiotics 
and needs physical therapy and occupational therapy. 
 
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 considered medically reasonable and necessary in this case. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve long term acute care hospital (LTACH) services.  
 
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 lab services provided on June 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical records. 
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, for 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 June 7, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has pay for the interpretation of a computed tomography (CT) scan provided on 
August 5, 2022, as billed. 
 
You asked the Plan pay for the inpatient services as billed. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says that these services were paid for on August 25, 
2022. Therefore, this is a duplicate claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan failed to support its denial by not submitting proof that payment was 
made for this service. As such, the denial of payment as a duplicate claim is not substantiated. Therefore, we 
decided that the Plan has pay for the interpretation of a computed tomography (CT) scan provided on August 5, 
2022, as billed.  
 
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: Favorable

 
We decided that the Plan has to pay for laboratory testing (88361, 88312, 88305) provided on March 11, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the requested testing is not covered. The enrollee's plan covers necessary 
services and supplies to treat a disease or injury. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for laboratory testing. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found according to Medicare, a service is medically reasonable and necessary if it is safe and effective 
and not mainly for the convenience of the enrollee or the physician. In order to be considered medically 
necessary a service cannot be investigational or experimental and must be ordered by qualified personnel and 
be appropriate to the enrollee's medical needs and condition. Additionally, there must be an appropriate 
duration and frequency that is considered appropriate for the service. The billed codes are for surgical 
pathology, gross and microscopic examination (88305), pathology and laboratory/surgical pathology for special 
stained specimen slides to identify organisms (88312) and microscopic genetic analysis of a tumor (88361). In 
this case, the enrollee was being evaluated with a procedure in which tissue biopsies were taken. The billed 
services were medically necessary to evaluate the tissue for possible cancer and microorganisms. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laboratory testing have been met. Therefore, we decided that the Plan has to pay 
for laboratory testing (88361, 88312, 88305) provided on March 11, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2. 
 
You asked the Plan to pre-approve a Freestyle Libre 2. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. 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. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 2 have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce your copayment for the pacemaker check provided from 
March 21, 2022, to September 26, 2022. 
 
You asked the Plan to reduce your copayment for the pacemaker check. You say that you consider the service 
at issue to fall under the outpatient diagnostic tests and therapeutic services benefit category. 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 $150 
copayment for outpatient hospital services.  
 
You have been asked to pay $38.54 for each pacemaker check, which is less than the standard $150 copayment 
per pacemaker check. The total you owe is $115.62 ($38.54 x 3 = $115.62). This item/service falls within the 
outpatient hospital services benefit category. 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 reduce your copayment for the 
pacemaker check provided from March 21, 2022, to September 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Orencia. 
 
You asked the Plan to pre-approve Orencia. You say that this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the Plan requires a trial of Stelara before it will approve 
Orencia. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Orencia. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Orencia. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drug of Stelara. The record does not show that this drug 
would likely be less effective and/or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orencia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Orencia.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the breast. 
 
You asked the Plan to pre-approve an MRI of the breast. You say that the enrollee has a history of breast 
cancer, and the requested breast MRI is necessary for follow-up due to the history of underestimation by 
routine 3D mammogram. The Plan denied your request. The Plan says the requested MRI is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that MRIs of the breast are covered for certain medical 
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 an MRI of the breast. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the enrollee has Ductal 
carcinoma in situ (DCIS). The enrollee does not have an inconclusive diagnosis. Evaluation of a post-operative 
patient when scar tissue cannot be differentiated from tumors, is not at issue. The enrollee does not have positive axillary nodes, but no known primary. The enrollee does not have a ruptured breast implant. The 
requested MRI is not needed to determine the extent of disease in a patient with known malignancy, prior to 
treatment. Our physician reviewer found that a mammogram should be done, and if inconclusive an MRI 
should then be considered. 
 
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 MRI of the breast have not been met. Therefore, we decided that the Plan 
does not have to pre-approve magnetic resonance imaging (MRI) of the breast.