Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the visual field examination (92083) and fundus photography with 
interpretation and report (92250) provided on September 22, 2022. 
 
You asked the Plan to pay for the visual field examination and fundus photography. You say that you were 
diagnosed with cataracts and had a special exam done. You also say that you cannot afford these services. The 
Plan denied your request. The Plan says that your benefit does not cover these services. 
 
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 records do not support that these services are not covered. This means that 
the Plan has not provided a valid reason for denying payment of the visual field examination and fundus 
photography. It is the burden of the Plan to substantiate their denial with evidence. In this case, the denial has 
not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the 
visual field examination (92083) and fundus photography with interpretation and report (92250) provided on 
September 22, 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 replacement power wheelchair. 
 
You asked the Plan to pre-approve a replacement power wheelchair. You say that the enrollee's current power 
wheelchair needs to be replaced. You say that the motors are worn and no longer useful, the batteries do not 
hold a charge, the tires, casters and bearings are worn, and the electronics are failing. The Plan denied your 
request. The Plan says replacement of your power wheelchair due to wear cannot be covered during the 
reasonable useful lifetime of the equipment, or less than 5 years. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement of items due to irreparable wear 
takes into consideration the Reasonable Useful Lifetime (RUL) of the item.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a replacement power wheelchair have not been met. The record shows that the enrollee's current 
power wheelchair was delivered less than 5 years ago. Therefore, we decided that the Plan does not have to 
pre-approve a replacement power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported porcelain/ceramic crown (D6058) 
Tooth #4, 5, and 12. 
 
You asked the Plan to pre-approve the dental services. You say that you do not agree with the denial of the 
requested services. 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. This benefit includes the 
requested abutment supported porcelain/ceramic crown (D6058) but is limited up to two implants covered per 
year, or up to four implants covered per year for edentulous patients, covered one per tooth per life. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your Plan approved abutment supported porcelain/ceramic crown (D6058) Tooth #15 and 19 on 
February 12, 2023. Therefore, your benefit has been exhausted. Therefore, we decided that the Plan does not 
have to pre-approve abutment supported porcelain/ceramic crown (D6058) Tooth #4, 5, and 12.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown, core buildup services, and a prefabricated post and 
core (D2740, D2954, D2950) provided on November 1, 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 annual $1,000 dental benefit maximum 
allowance 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 October 6, 2022. 
Therefore, we decided that the Plan does not have to pay for a crown, core buildup services, and a prefabricated 
post and core (D2740, D2954, D2950) provided on November 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum-assisted sock system. 
 
You asked the Plan to pre-approve a vacuum-assisted sock system. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a vacuum-assisted sock system is only covered for 
certain 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 a vacuum-assisted sock system. Our 
reviewer says that the documentation does not support that the requested device is medically reasonable or 
necessary. Our physician reviewer found the enrollee's functional level is K3. The enrollee has increased 
activities of daily living. The literature reviewed indicates that further research is needed with clinical trials that 
recruit larger sample sizes and report long-term outcome data for the requested elevated vacuum suspension 
system. Therefore, the enrollee does not meet criteria for the requested item. 
 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 vacuum-assisted sock system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a vacuum-assisted sock system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 29, 2022. 
 
You asked the Plan to pay for the testing services. You say that the panel takes a deep look into tumor biology. 
The Plan denied your request. The Plan says the requirements for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. The medical records provided do not include definitive staging that 
shows the enrollee has advanced stage cancer. The records do not show that the enrollee is not treatable by 
resection or radiation with curative intent. Based on this information, we decided that Medicare rules for 
coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for 
the genetic testing provided on August 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an immediate maxillary partial denture (D5227) provided on 
November 22, 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 the services denied correctly as they do not fall 
within your dental 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. 
 
 
  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 an 
immediate maxillary partial denture (D5227) provided on November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for A limited clinical inspection (D0191) provided on September 
14, 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 the services denied correctly as they do not fall 
within your dental 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. 
 
 
  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 
clinical inspection (D0191) provided on September 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT) services. 
 
You asked the Plan to pre-approve PBRT services. You say that the clinical information provided shows that 
the enrollee meets the criteria for coverage of PBRT. The Plan denied your request. The Plan says there is not 
enough medical evidence to show that this type of radiation treatment is more effective or has less side effects 
than other forms of radiation therapy for prostate cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve PBRT services. Our reviewer says that 
PBRT is not considered medically reasonable and necessary in this case. Our physician reviewer found there is 
no compelling data to suggest that proton therapy is superior to or more beneficial than intensity modulated 
radiotherapy (IMRT)/image guided radiotherapy (IGRT.) The generally accepted standard of care for prostate 
cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. While 
National Comprehensive Cancer Network (NCCN) guideline consider proton therapy a reasonable 
alternative they do not describe it as being necessary in lieu of non-proton based treatment and are quite 
explicit in that there is no evidence of its superiority. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam radiation therapy (PBRT) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95885, 95937, and 95907 provided on 
August 17, 2021. 
 
You asked the Plan to pay for procedure codes 95885, 95937, and 95907. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
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 95885 is needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
limited (List separately in addition to code for primary procedure). 
 
The CPT Code Manual definition of code 95907 is nerve conduction studies; 1-2 studies. 
 
The CPT Code Manual definition of code 95937 is Neuromuscular junction testing (repetitive stimulation, 
paired stimuli), each nerve, any 1 method. 
 
We find that CPT codes 95885, 95937, and 95907 are not supported in the medical record. Specifically, the 
technical report did not include documentation of a needle electromyography, for each extremity, with related 
paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited 
(listed separately in addition to code for primary procedure); therefore, code 95885 cannot be verified. 
 
The technical report did not include documentation of neuromuscular junction testing (repetitive stimulation, 
paired stimuli), per each nerve, by any 1 method; therefore, code 95937 cannot be verified. 
 
The technical report did not include documentation of nerve conduction studies; 1-2 studies; therefore, code 
95907 cannot be verified. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 95885, 95937, and 
95907 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 95885, 
95937, and 95907 provided on August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on August 3, 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 the services denied correctly as they do not fall 
within your dental 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. 
 
 
  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 
consultation (D9310) provided on August 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. 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 SBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has widespread disease (with multiple prior courses of radiotherapy) and the plan is 
to only treat a painful metastasis at T8. It is reasonable to offer this enrollee palliative radiotherapy, perhaps 
with techniques and doses in excess of the standard 2D palliative regimens, but there is not an evidenced based rationale for SBRT in this 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 SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve stereotactic body radiation therapy (SBRT).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Computed tomography (CT) of the chest. 
 
You asked the Plan to pre-approve the CT of the chest. You say that the services are necessary to follow up on 
lung nodules. The Plan denied your request. The Plan says they cannot approve this scan without more notes 
from the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 the CT of the chest. Our reviewer says 
that the CT scan of the chest is not medically necessary. Our physician reviewer found there are no notes or 
records concerning the scheduled CT of the chest of May 13, 2021. Fleischner Society criteria indicates a 
follow up for 2 nodules less than 6 millimeters in diameter is not necessary unless the enrollee is at high risk 
for lung cancer. There are no notes concerning whether the scheduled CT of May 13, 2021, has been 
completed. The requested CT of the chest cannot be determined based on the submitted records. 
 
 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 CT of the chest have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Computed tomography (CT) of the chest.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on November 15, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that you were advised this service was covered under 
your insurance. The Plan denied your request. The Plan says a resolution was not provided within the required 
60-day timeframe for the appeal received on December 16, 2022. 
 
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 eye refractions associated with a Medicare-covered eye exam. 
 
 
 
 
 We looked at the file and the Plan's rules. Specifically, the record shows that you received a medical eye exam 
for the diagnoses of H43.393, defined as Other vitreous opacities, bilateral, and H52.03, defined as 
Hypermetropia, bilateral. This refraction was not provided with a Medicare-covered eye exam. Based on this 
information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, 
we decided that the Plan does not have to pay for the eye refraction (92015) provided on November 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0299, Q5001) provided on January 
26, 2022, to February 24, 2022. 
 
You asked the Plan to pay for the home health services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 26, 2022. The NOA was not received by the Plan until March 21, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services (G0299, 
Q5001) provided on January 26, 2022, to February 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0245U billed for date of service February 3, 
2022. 
 
You asked the Plan to pay for procedure code 0245U. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 0245U is bundled into payment for code 0018U. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 0245U 
is a column II code to column I code 0018U. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 0245U billed for date of service February 3, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy (36475). 
 
You asked the Plan to pre-approve endovenous ablation therapy. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that 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 endovenous ablation therapy. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there is no reflux 
throughout the great saphenous vein bilaterally other than at the origin, an area that is precluded from ablation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve endovenous ablation therapy (36475).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you believe that the enrollee still requires skilled 
care to receive therapy services before returning home. The Plan denied your request. The Plan says the 
services are not medically necessary. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.