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

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine without contrast. 
 
You asked the Plan to pre-approve the MRI. You say that it is medically necessary for the enrollee to get an 
MRI done. The Plan denied your request. The Plan says the enrollee has not completed 6 weeks of provider 
directed treatment and the provider directed treatment did not occur within the last 3 months; therefore, the 
MRI is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the 
MRI of the lumbar spine is not medically necessary. Our physician reviewer found that more conservative 
measures are needed including 6 weeks of physical therapy for back pain. 
 
  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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine without contrast.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract surgery. 
 
You asked the Plan to pre-approve cataract surgery. You say that the service is medically necessary. The Plan 
denied your request. The Plan says there is no documentation of visual complaints or interference in ADLs. 
 
The Plan follows Medicare rules. Medicare rules say that cataract surgery will be covered when the criteria 
listed in the Medicare Rules section has been 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 cataract surgery. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found there is no documentation of a cataract 
causing symptomatic impairment of visual function resulting in the patient's inability to function satisfactorily 
while performing Activities of Daily Life, concomitant intraocular disease, Lens-induced disease threatening 
vision or ocular health, High probability of accelerating cataract development as a result of a concomitant or 
subsequent procedure, Cataract interfering with the performance of vitreoretinal surgery, or intolerable 
anisometropia or aniseikonia uncorrectable with glasses or contact lenses that exists as a result of lens 
extraction in the first eye (despite satisfactorily corrected monocular visual acuity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cataract surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve cataract surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction of an erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210) for teeth numbers 20, 21, and 22 provided on August 8, 2022. 
 
You asked the Plan to pay for the extraction of an erupted tooth requiring removal of bone and/or sectioning of 
tooth (D7210) for teeth numbers 20, 21, and 22. You say that you had one tooth that was abscessed, and the 
dentist had to remove the teeth on either side. The Plan denied your request. The Plan says this service is not 
covered under your comprehensive dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
extraction of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) for teeth numbers 
20, 21, and 22 provided on August 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care services provided from February 19, 2022, 
to March 10, 2022. 
 
You asked the Plan to pay for home health care. You say that you are requesting reprocessing of this claim. 
The Plan denied your request. The Plan says this claim was not billed with an appropriate Q- code. 
 The Plan must follow Medicare rules. Medicare rules say that home health agencies must report the location of 
service by billing one unit of code Q5001, Q5002, or Q5009.  
 
We looked at the file and Medicare rules. This claim was not billed with an appropriate Q- code. Based on this 
information, we decided that Medicare rules for coverage of home health care have not been met. Therefore, 
we decided that the Plan does not have to pay for home health care services provided from February 19, 2022, 
to March 10, 2022.
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 ventilator. You say that the enrollee feels better using the equipment. The 
Plan denied your request. The Plan says the requested mode could be provided by a BiPAP device. 
 
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 ventilator. Our physician reviewer 
found that the enrollee has a diagnosis of COPD. She was recently hospitalized with pneumonia and COPD 
exacerbation. Arterial blood gas (ABG) levels were consistent with acute on chronic hypercarbic respiratory 
failure. There is no ABG done while stable to confirm chronic carbon dioxide (CO2) retention. If that is 
confirmed, the enrollee may benefit from BiPAP during sleep as an outpatient.  However, Medicare does not 
cover a home ventilator when used as a BiPAP. Therefore, a home ventilator 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 2, 2022, to July 
31, 2022. 
 
You asked the Plan to pay for the home health services. You say that the notice of admission was submitted 
timely. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment have not been met. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from July 2, 2022, to July 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the 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 the dental 
services on August 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the requested bed is medically 
necessary due to unspecified fracture of upper end of left radius, initial encounter for closed fracture. The Plan 
denied your request. The Plan says the documentation does not indicate that you require frequent and 
immediate need for a change in body position to qualify for a semi-electric hospital bed. Furthermore, if you 
qualify for a hospital bed, both the fixed height and variable height allow for elevation of the head and foot of 
bed with only the control mechanisms differing from the semi-electric bed. 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found you have multiple 
fractures after falling out of a tree stand. You have generalized relatively constant pain. You do require re-
positioning. There is no evidence you require immediate re-positioning for your chronic pain. You do not 
require positioning not available with a standard bed. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 24, 2022, 
to March 25, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the claim has not been 
billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 24, 2022, to 
March 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on April 21, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you are disputing the share 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 $20 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $20 copayment for office visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits 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 waive the copayment for office visit provided on April 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 18, 2022. 
 You asked the Plan to pay for the lab services. You say that the test clarifies disease risk. The Plan denied your 
request. The Plan says the test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The file shows that a hereditary cancer panel was provided. We looked at the file and the rules. The records do 
not show that the testing was ordered based on signs and symptoms the enrollee was experiencing. This testing 
is not covered for screening services. Furthermore, the panel testing was not billed with a single code as 
required. 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 pay for the lab services provided on July 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mammogram provided on July 7, 2022. 
 
You asked the Plan to waive the copayment for a mammogram. You say that you disagree with the copayment. 
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 $160 
copayment for outpatient diagnostic tests/Medicare-covered special imaging.  
 
You have been asked to pay a $160 copayment for a mammogram. However, you are only being asked to pay 
$147.33 which is less than the required amount. This item/service falls within the outpatient diagnostic 
tests/Medicare-covered special imaging 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 waive the copayment 
for a mammogram provided on July 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation (RFA) services. 
 
You asked the Plan to pre-approve genicular RFA services. You say that the documentation provided supports 
the need or the requested services. The Plan denied your request. The Plan says the requested procedure is 
considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve genicular RFA services. Our reviewer 
says that the requested RFA services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has osteoarthritis of her left knee. The enrollee had prior RF of the left 
genicular nerves. The requested repeat RFA services are considered an experimental/investigational procedure 
that is currently the subject of ongoing clinical trials. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular RFA services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular radiofrequency ablation (RFA) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy. You say that you have made significant progress since the 
initiation of care now as evidence by good tolerance to high level strengthening exercises and balance 
activities. You say that you have not needed to use of a manual wheelchair or transport chair for any of your 
mobility for several weeks while also being compliant with your home exercise program and continue to 
demonstrate good potential to achieving full functional independence. The Plan denied your request. The Plan 
says additional physical therapy visits are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that you are more than six months past having a stroke and are 
receiving repetitive exercises with non-skilled range of motion during physical therapy sessions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical 
x-ray (D0220), bitewing x-rays (D0274), and prophylaxis (D1110) provided on July 19, 2022, by an out-of-
network provider. 
 
You asked the Plan to pay for the dental services. You say that when you went to your regular dentist, you were 
informed that they accepted your insurance. You also say that you would like to appeal and see if the Plan can 
pay part, if not all, of the bill. The Plan denied your request. The Plan says the dental services were received 
from an out-of-network provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), bitewing x-rays 
(D0274), and prophylaxis (D1110) provided on July 19, 2022, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) and 
supplies (K0553). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that daily work and family stress cause your 
blood sugar to increase. You have had type 2 diabetes for over 50 years. Your blood sugar drops during sleep at 
night. You feel that more often and quicker glucose monitoring would be beneficial for your diabetes. The Plan 
denied your request. The Plan says your request is not medically necessary because your records show you do 
not have either an insulin pump or multiple daily administrations of insulin. 
 
 
 
 
 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 or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous 
glucose monitor (CGM) and supplies (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on July 7, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you are disputing the share 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 $40 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $40 copayment for office visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits 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 waive the copayment for office visit provided on July 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 provided on June 30, 2022. 
 
You asked the Plan to pay for the billed services. You say that drug testing is needed to monitor possible opioid 
abuse. The Plan denied your request. The Plan says the code cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. We find that the testing described by code 83789 is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 83789 provided on June 30, 2022.