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

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. You say that the standard of care has not been 
effective. The Plan denied your request. The Plan says the device is considered unproven. 
 
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 requested services. Our physician 
reviewer found that the enrollee has recurrent congestive heart failure (CHF). The device allows measurement 
of pulmonary artery pressure in the management of patients with CHF. There remains a dearth of randomized, 
blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in 
patient management. As a result, at this time the CardioMEMS system would not be considered medically 
appropriate and necessary in this enrollees clinical management. 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 
You asked the Plan to pre-approve Eylea. The Plan denied your request. The Plan says this request is for an 
off-label use that is not medically accepted. 
 
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 Eylea. Our reviewer says that Eylea is 
not FDA approved for the enrollee's diagnosis of cystoid macular edema due to radiation retinopathy. Our 
physician reviewer found the use of Eylea is not supported by the approved compendia or medical journal. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental out-patient teeth extractions. 
 
You asked the Plan to pre-approve the dental out-patient teeth extractions. You say that these services are 
connected to a sinus surgery that has to be performed on May 15, 2023. You also say that two teeth have to be 
extracted in order to reach the infected area. The Plan denied your request. The Plan says this service is not 
covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental out-patient teeth extractions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on September 21, 
2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says durable medical equipment is 
not covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the durable medical equipment provided on September 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan. 
 
You asked the Plan to pre-approve a PET scan. You say that the PET scan is medically necessary. The Plan 
denied your request. The Plan says that the requested PET scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 a PET scan. Our reviewer says that the 
requested PET scan is not medically necessary. Our physician reviewer found that advanced imaging is not 
generally needed for initial staging of prostate cancer. Clinicians should not routinely perform abdomino-pelvic 
computed tomography (CT) scans or bone scans in asymptomatic patients with low or intermediate risk 
prostate cancer. Clinicians should obtain a bone scan and either pelvic multi-parametric magnetic resonance 
imaging (mpMRI) or a CT scan for patients with high-risk prostate cancer. 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a PET scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that it is a sad day when a device that could 
save the enrollee's lift is called a hygiene product and is denied. You also say that you will buy this out of your 
own pocket. The Plan denied your request. The Plan says the requested item is not covered by Medicare or the 
Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
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 
November 7, 2022, to November 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 August 20, 2021, and 
August 30, 2021. Therefore, we decided that the Plan does not have to pay for periodontal scaling and root 
planing (D4341) provided on November 7, 2022, to November 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex walk system (L5981, L5986). 
 
You asked the Plan to pre-approve a flex walk system. 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 follows Medicare rules. Medicare rules say that a determination of the type of foot for the prosthesis 
will be made by the treating practitioner and/or the prosthetist based upon the functional needs of the 
beneficiary. 
 
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 flex walk system. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there are no objective criteria 
offered indicating the enrollee is a K3 ambulator. The enrollee's prior status was closer to K2 than K3. 
 
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 flex walk system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a flex walk system (L5981, L5986).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lens and the miscellaneous vision provided on December 
19, 2022. 
 
You asked the Plan to pay for the lens and the miscellaneous vision. You say that you are requesting to be 
reimbursed more for your eyewear. The Plan denied your request. The Plan says the benefit limitation has been 
exhausted. 
 
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 vision services up to $200. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $200 towards vision services on February 
14, 2022, which exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage 
of the lens and the miscellaneous vision have not been met. Therefore, we decided that the Plan does not have 
to pay for the lens and the miscellaneous vision provided on December 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluid circulating cold pad with pump (E0218) provided 
on September 26, 2022. 
 
You asked the Plan to pay for the cold pad with pump. You say that you need this for after your surgery. You 
say that you were in a lot of pain. You also say that these items were very helpful. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the cold pad with pump have not been met. Therefore, we decided that the Plan does not have to 
pay for the fluid circulating cold pad with pump (E0218) provided on September 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found detailed documentation is not evident regarding a significant past and/or 
current medical history that would place this enrollee at increased risk for peri-surgical complications requiring 
an inpatient stay. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the record does not show that the admitting 
physician reasonably would expect the enrollees necessary hospital care would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 6, 2022, by an out-
of-network (OON) provider. 
 
  You asked the Plan to pay for the medical services. You say that you would like this claim to be reprocessed 
for payment. The Plan denied your request. The Plan says the provider is OON with the enrollees medical 
group, and they should have obtained authorization prior to the service being rendered. The Plan also says the 
services were not urgent or emergent. 
 
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 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 the medical services provided on January 6, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultraviolet (UV) light therapy cabinet (E0694). 
 
You asked the Plan to pre-approve a UV light cabinet. You say that you are currently receiving full body UVB 
phototherapy on an outpatient basis. You say that this requires the enrollee to drive 30 minutes each way, two 
days per week. You say that the enrollee is expected to pay $100 per session. You also say that the enrollee 
should have access to an at-home phototherapy unit. The Plan denied your request. The Plan says items 
requested for convenience are not a covered benefit. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an ultraviolet (UV) light therapy cabinet (E0694).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the admission to a LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided 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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 8, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on December 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spine fusion surgery. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has tried conservative 
treatment. 
 The Plan denied your request. The Plan says the services are 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 pre-approve the requested services. Our physician 
reviewer found that there is no documentation of an epidural steroid injection. There is no documented 
instability. Therefore, surgery not medically necessary 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve spine fusion surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the stabilization device insertion. 
 
You asked the Plan to pre-approve the stabilization device insertion. You say that you have had continuous 
pain for the past year which is affecting your ability to walk. The Plan denied your request. The Plan says these 
devices as a stand-alone procedure are considered 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 stabilization device insertion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found current evidence based medical guideline does not fully support the spinal 
decompression device procedure over the standard lumbar laminectomy. There is a lack of large volume, long-
term studies to support the use of this device for the enrollees 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 stabilization device insertion have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the stabilization device insertion.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrodes (A4595) provided on December 1, 2022. 
 
You asked the Plan to pay for the supplies. You say that the supplies were billed correctly. The Plan denied 
your request. The Plan says that the documentation supplied does not support the billed code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record contains a valid physician order and proof of delivery for the supplies provided in this case. 
Therefore, we decided that the Plan has to pay for the electrodes (A4595) provided on December 1, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Osteocel Allograft (20930). 
 
You asked the Plan to pre-approve Osteocel Allograft. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Osteocel Allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested Osteocel Allograft, in 
this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Osteocel Allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Osteocel Allograft (20930).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical imaging (D0220) provided on August 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. 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 August 16, 2022, with D0230. Therefore, we decided that the Plan does not have to pay for periapical imaging (D0220) provided on 
August 16, 2022.