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

 
We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
two or more power seating system (E2311) harness for upgrade to expandable controller, including all 
fasteners, connectors and mounting hardware (E2313) expandable controller, including all related electronics 
and mounting hardware, upgrade provided at initial issue (E2377). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that please reconsider these three very 
important functions since they are the only way the enrollee can safely and independently use the approved 
seating functions of the chair. The Plan denied your request. The Plan says the available medical records do not 
support necessity of the equipment as defined by Medicare 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 pre-approve the upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no documentation that the enrollee 
meets the criteria as detailed in the Local Coverage Article for Medicare coverage for the requested power 
wheelchair accessories. Provided records document that the enrollee is independent with feeding and grooming 
with set-up thus indicating he has adequate upper extremity strength and function to operate the wheelchairs 
power options with their own switches. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electronic connection between wheelchair controller and two or more power 
seating system (E2311) harness for upgrade to expandable controller, including all fasteners, connectors and 
mounting hardware (E2313) expandable controller, including all related electronics and mounting hardware, 
upgrade provided at initial issue (E2377).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by an out-of-
network provider on September 28, 2021. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you were unaware this provider was out-
of-network. The Plan denied your request. The Plan says D0140 is not a covered dental 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 limited 
oral evaluation (D0140) provided by an out-of-network provider on September 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274), periodic 
oral evaluation - established patient (D0120), and prophylaxis - adult (D1110) provided October 28, 2021. 
You asked the Plan to pay for the bitewing x-rays, periodic oral exam and dental cleaning. You say that you 
were not told that this provider has opted out of Medicare. The Plan denied your request. The Plan says these 
services are not covered because the provider has opted out of Medicare. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the bitewing 
x-rays, periodic oral exam and dental cleaning when you see any licensed dental provider who accepts 
Medicare patients in the United States and has not opted out of Original Medicare. 
 
We looked at file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-
emergent situation by the provider who has opted out of the Medicare program. Based on this information, we 
decided that the Plan's rules for coverage of the bitewing x-rays, periodic oral exam and dental cleaning have 
not been met. Therefore, we decided that the Plan does not have to pay for the bitewings - four radiographic 
images (D0274), periodic oral evaluation - established patient (D0120), and prophylaxis - adult (D1110) 
provided October 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled 
nursing needs or documented skilled therapy needs. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of your condition. Your care needs, custodial and intermittent, 
can, as a practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says the record 
does not show that you require daily skilled nursing or skilled therapy in a SNF setting. The Plan also says that 
the services you require are called custodial care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 the SNF services. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a SNF setting. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided from 
September 20, 2021, to September 21, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the enrollee was not 
enrolled in hospice on the date of service in this case. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 4, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care (99233) provided from September 20, 2021, to September 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 21, 
2021, to June 25, 2021. 
 
You asked the Plan to pay for the inpatient care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the inpatient level of care was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient care. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. 
 Our physician reviewer found the provided documentation does not indicate that the enrollee required any 
inpatient diagnostic studies or therapeutic interventions. The review has determined that the inpatient hospital 
services April 21, 2021, to April 25, 2021 were not medically necessary or reasonable. 
 
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 inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pay for the acute inpatient hospital care provided from June 21, 2021, to June 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466) for the enrollee. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested home ventilator is not medically reasonable and 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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the enrollee 
was recently hospitalized with mental status changes and found to be in hypercarbic respiratory failure. The 
enrollee improved on bilateral positive airway pressure (BiPAP). There is no diagnosis of COPD, thoracic 
restrictive disease, or neuromuscular disease. There is a diagnosis of elevated hemidiaphragm, but this is not 
supported by the chest radiography (CXR) report. There are no pulmonary function tests.  Obstructive sleep apnea is not considered. This patient may benefit from treatment with BiPAP during sleep. 
But, Medicare does not cover a home ventilator when used as BiPAP. The patient does not have a diagnosis for 
which Medicare covers a home ventilator. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator (E0466) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
December 20, 2021. 
 
You asked the Plan to pay for the dental service. You say that you will not pay for any additional charges. You 
say that you requested a cleaning that was covered under your insurance, nothing more. You also say that you 
will not be returning to this establishment. The Plan denied your request. The Plan says a comprehensive oral 
evaluation is covered once every 3 calendar years. The Plan also says that the frequency limit has been 
exceeded. 
 
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 and a comprehensive oral evaluation is covered once every 3 calendar years, the frequency limit has been exceeded. The record shows that the Plan 
paid for a comprehensive oral evaluation that you received on July 19, 2021. Therefore, we decided that the 
Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on December 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you would like reconsideration for the 
incontinence supplies to be approved. The Plan denied your request. The Plan says these items are not covered 
under any condition. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120) 
provided December 21, 2021. 
 
You asked the Plan to pay for the periodic oral exam. You say that your policy has always been for 2 cleanings 
per year, not one every six months. The Plan denied your request. The Plan says you have exceeded the 
frequency limit for this service. 
 
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 Plan covers the periodic 
oral exam twice per plan year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a periodic exam was 
previously covered on June 22, 2021, and September 8, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the periodic oral exam has been exceeded. Therefore, we decided that the 
Plan does not have to pay for the periodic oral evaluation - established patient (D0120) provided December 21, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve genicular nerve RFA. You say that you have terrible pain and this procedure 
helped before. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because studies have not proven that this procedure is helpful for your condition. 
 
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 nerve RFA. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve blocks and radiofrequency ablations (RFAs) are considered 
investigational for the treatment of chronic knee 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 genicular nerve RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve radiofrequency ablation (RFA).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82270 and 36415) provided on 
August 2, 2021. 
 
You asked the Plan to pay for codes 82270 and 36415. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are 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. 
 
In this case, the CPT Code Manual definition of code 82270 is Blood, occult, by peroxidase activity (eg, 
guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards or single triple card for consecutive collection). The definition of 
code 36415 is Collection of venous blood by venipuncture. 
 
We find that CPT codes 82270 and 36415 are not supported in the medical record. Specifically, the medical 
records provided do not describe consecutive collected specimens for colorectal neoplasm screening or 
collection of venous blood by venipuncture. Based on this information, we decided that Medicare rules for 
coverage of codes 82270 and 36415 have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory services (82270 and 36415) provided on August 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of an Optimesh device (22853). 
 
You asked the Plan to pre-approve the insertion of an Optimesh device. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is experimental. 
 
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 the insertion of an Optimesh device. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is a lack of large volume, long-term peer-reviewed outcome studies to 
support the use of this device for this enrollee's medical condition. 
 
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 insertion of an Optimesh device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the insertion of an Optimesh device (22853).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the spherocylinder, single vision, 
plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens (V2103) and anti-reflective coating 
(V2750) provided January 10, 2022. 
 
You asked the Plan to provide additional payment for the lenses with anti-reflective coating. You say that you 
would like your $250 allowance applied to your claim. The Plan denied your request. The Plan says your $250 
allowance has been applied to your claim. You are responsible for the remaining cost. 
 
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 routine eyewear up to a $250 allowance. 
 
We looked at the file and the Plan's rules. The Plan provided documentation showing that your full $250 
allowance was applied to the routine eyewear purchased on January 10, 2022. You are responsible for the 
remaining cost over $250. Therefore, we decided that the Plan does not have to provide additional payment for 
the spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per lens (V2103) 
and anti-reflective coating (V2750) provided January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide an office visit to an OON provider. 
 
You asked the Plan to provide the office visit. You say that the Plan-provided doctors do not apply to you. The 
Plan denied your request. The Plan says there are doctors in network that can provide the requested service. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 provide the office visit. Our reviewer says that you 
do not meet the Medicare criteria for treatment with an out-of-network provider. Our physician reviewer found 
the Plan denial is justified. There is nothing in the available records to support the necessity of seeing an OON 
provider, and the Plan-provided in-network care meets standard-of-care appropriate to your treatment and 
conditions. 
 
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 office visit have not been met. Therefore, we decided that the Plan does not 
have to provide an office visit to an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 2, 2021. 
 
You asked the Plan to pay for the lab services. You say that there is no agreement that the codes are included in 
the dialysis rate. The Plan denied your request. The Plan says the tests are the responsibility of the dialysis 
center. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on August 2, 2021.