Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that the records provided support the need for the requested 
drug. The Plan denied your request. The Plan says the Part B Step Therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of an oral and/or 
an injectable bisphosphonate before they will approve the requested drug. In this case, the enrollee has not tried 
and failed the required drugs. There is no documentation provided indicating that the Plans required drugs 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pulmonary stress test provided on January 17, 2023. 
 
You asked the Plan to pay for a pulmonary stress test. You say that patient does not have out-of-network 
benefits, you are submitting documents to support payment. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a pulmonary stress test 
provided on January 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy (D3310) for tooth #11 provided by an 
out-of-network provider on November 28, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental service was not completed, and you 
would like the claim to be rescinded and rebilled when it is completed. The Plan denied your request. The Plan 
says your maximum dental benefit for the year has already been exhausted. Also, it was verified the proper 
billing and services were completed. 
 
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. On January 
27, 2022, the Plan paid $122 for dental services. On August 10, 2022, the Plan paid $174 for dental services. 
On August 23, 2022, the Plan paid $204 for dental services. For the year of 2022 the Plan paid $500 ($122 paid 
+ $174 paid + $204 paid) for dental services; therefore, your dental benefit for the year of 2022 was exhausted 
on the date of service of August 23, 2022. Therefore, we decided that the Plan does not have to pay for the 
endodontic therapy (D3310) for tooth #11 provided by an out-of-network provider on November 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a user adjustable heel height prosthetic component 
(L5990). 
 
You asked the Plan to pre-approve a user adjustable heel height. You say that your gait is off due to a birth 
defect. You say that you have tried different feet that were not successful. You also say that you need this so 
you can get around. The Plan denied your request. The Plan says the requested component is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a user-adjustable heel height feature (L5990) 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 a user adjustable heel height have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a user adjustable heel height prosthetic component (L5990).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee meets all the guidelines to be 
approved for this device. The Plan denied your request. The Plan says based on Medicare guidelines, the 
noninvasive ventilator requested does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says that the service is not medically necessary. Our physician reviewer found that this enrollee has a diagnosis of 
chronic obstructive pulmonary disease (COPD) and was recently hospitalized with an exacerbation. Arterial 
blood gas (ABG) was consistent with mild acute on chronic hypercarbic respiratory failure. There are no 
pulmonary function tests to assess severity of the COPD. There is no ABG done while stable to confirm 
chronic CO2 retention. If the enrollee does have chronic CO2 retention, may benefit from bilevel positive 
airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep as an 
outpatient. Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional panoramic radiographic image (D0330), and 
comprehensive oral evaluation (D0150) provided on December 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you asked the dentist to perform covered only 
procedures. 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 additional panoramic radiographic image (D0330) was exhausted on the appealed 
claim, and the comprehensive oral evaluation (D0150) was exhausted on date of service October 28, 2020.  
Therefore, we decided that the Plan does not have to pay for an additional panoramic radiographic image 
(D0330), and comprehensive oral evaluation (D0150) provided on December 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prophylaxis - adult (D1110) provided on December 14, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you are asking for the Plan to review and 
reconsider payment. 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 service was exhausted on date of service February 15, 2022, and June 15, 
2022. Therefore, we decided that the Plan does not have to pay for a prophylaxis - adult (D1110) provided on 
December 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service November 
26, 2022. 
 You asked the Plan to pay for procedure code 76705. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into 
payment for code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service November 26, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound of the heart and the 
specialist visit provided on September 23, 2022, the stress test and the specialist visit provided on September 
30, 2022, the external electrocardiographic recording provided on October 3, 2022, and the specialist visit 
provided on October 28, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound, the stress test, the electrocardiographic 
recording, and the specialist visits. You say that you are unable to pay for these services. 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 $155 
copayment for Medicare-covered radiological diagnostic services, which includes ultrasounds, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic), a $40 copayment 
for Medicare-covered non-radiological diagnostic services, which includes electrocardiograms (EKGs), and 
treadmill stress tests, and a $25 copayment for services obtained from a specialist, or under certain 
circumstances, treatment by a nurse practitioner or physicians assistant or other non-physician health care 
professionals in a specialists office. 
 
You have been asked to pay a $155 copayment for the ultrasound, a $40 copayment for the stress test, and a 
$40 copayment for the electrocardiographic recording. These items/services fall within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. You have also been asked to pay a $75 
copayment for the specialist visits ($25 x 3 visits = $75). These items/services fall within the 
physician/practitioner services, including doctors office visits benefit category.  
 
You have been asked to pay a total cost share of $310 for the ultrasound, the stress test, the 
electrocardiographic recording, and the specialist visits ($155 + $40 + $40 + $75 = $310). 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 the ultrasound of the heart and the specialist visit provided on 
September 23, 2022, the stress test and the specialist visit provided on September 30, 2022, the external 
electrocardiographic recording provided on October 3, 2022, and the specialist visit provided on October 28, 
2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found based on review of the records, the enrollee with recent hospitalization for colon surgery for a mass 
meets criteria for coverage for an IRF admission due to enrollee's medical needs and skilled therapy needs. The 
enrollee needs physician supervision 3 times per week for the ongoing management of any active or acute 
exacerbations of chronic medical conditions. Documentation supports the need for therapy program consisting 
of at least 3 hours of therapy per day at least 5 days per week. She is improving functionally. There is clear 
evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician 
oversight and an interdisciplinary approach to rehabilitation care. IRF admission is medically necessary based 
on medical complexity and identified skilled rehab therapy needs. The enrollee's rehabilitation needs justify an 
admission to an IRF given she was very functional prior to the surgery and is making progress in therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve otolaryngology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the provider performs the surgery needed. The 
Plan denied your request. The Plan says services are available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
otolaryngology services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on February 14, 2022, to February 
15, 2022, and March 15, 2022. 
 
You asked the Plan to pay for the testing services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 93010 and 99239 is  
electrocardiogram, routine ECG with at least 12 leads; interpretation and report only, and  
hospital discharge day management; more than 30 minutes  
 
We asked our coder 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 testing services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found the documentation does not contain an 
interpretation and report for a 12 lead ECG. It cannot be verified that this service was provided. The 
documentation for the discharge date does not specify how much time was spent on discharge management 
services. It cannot be confirmed that more than 30 minutes was spent. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of testing services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for testing services provided on February 14, 2022, to February 15, 2022, and March 
15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs rehabilitation to be able to walk 
again after surgery. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you are a cancer survivor, have chronic 
diabetes, and suffer from a skin condition where you bruise by a touch. You also say that you are a low income 
person, with no internet or computer to be aware of these benefits. The Plan denied your request. The Plan says 
you do not qualify for services under the SSBCI program. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of SSBCI benefits have been met. 
Medical records were not provided for this case. The record shows that the Plan made multiple attempts to 
obtain this information, but it was not received. Without medical records we are unable to determine if you 
meet the criteria for coverage. Therefore, we decided that the Plan does not have to pre-approve special 
supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and an appliance. You say that the device 
is medically necessary. The Plan denied your request. The Plan says the requested service is not medically 
necessary as it does not meet the LCD requirements for coverage. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and a segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667).