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

 
We decided that the Plan does not have to pre-approve acupuncture services under the patient's medical 
benefits. 
 
You asked the Plan to pre-approve the acupuncture services. You say that this patient requires acupuncture for 
treatment of tinnitus. The Plan denied your request. The Plan says under the patient's medical benefits, she is 
only covered for acupuncture for the treatment of chronic low back pain.  Acupuncture treatment for tinnitus is 
not covered under the patient's medical benefits. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. According to the case file, you are requesting coverage of acupuncture services for the 
treatment of tinnitus, which is not a Medicare covered benefit.  Therefore, there is no coverage for acupuncture 
under the patient's medical benefit (which is what you requested.) However, the Plan offers coverage beyond 
the Medicare acupuncture benefit when requested through the Plan's acupuncture participating provider plan.  
You did not request these acupuncture services through this plan. If you wish to pursue coverage of 
acupuncture under this benefit, the Plan has indicated that this would be coverable.  In fact, the Plan has 
reached out to the patient directly to advise them that they simply need to request these acupuncture services 
through this supplemental benefit instead of through the medical benefit as was done in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services under the patients medical benefit have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acupuncture services under the patient's medical benefits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lower spine 
for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no red flags for immediate imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found there are no red flags 
such as absent/diminished reflex or weakness. Absent this information, immediate MRI without a six week 
course of conservative therapy, including physical therapy, 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 the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lower spine for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported crowns (D6058 x 3), and 
prefabricated abutments (D6056 x 3). 
 
You asked the Plan to pre-approve the dental services. You say that the existing implants need to be restored 
with abutment and crown. You say that the implants were previously approved by the enrollee's plan and 
already placed. You also say that the enrollee does not have the finances to pay out of pocket. The Plan denied 
your request. The Plan says dental implants and all associated services are excluded from coverage. 
 
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 abutment supported 
crowns and prefabricated abutments are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve abutment supported crowns (D6058 x 3), and prefabricated abutments 
(D6056 x 3).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cardiology procedures to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the cardiology procedures. The Plan denied your request. The Plan says no 
medical need is shown as to why the enrollee cannot receive the vascular interventions from a provider in the 
Plan's network. The Plan also says that there is no network gap as there are available in-network providers. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the cardiology procedures to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from October 10, 2021, to November 8, 2021. 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled nurse or therapist need. 
 
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 pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found there 
are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from October 10, 2021, to 
November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the replacement of all teeth and acrylic on mandibular cast 
metal framework (D5671) provided on October 26, 2021. 
 
You asked the Plan to pay for the replacement of all teeth and acrylic on mandibular cast metal framework. 
You say that you would like this service to be covered. The Plan denied your request. The Plan says this 
service is not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
replacement of all teeth and acrylic on mandibular cast metal framework (D5671) provided on October 26, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 28, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill by Medicare coding regulations. 
 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 70450 
is a column II code to column I code 70496. 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 imaging services provided to the enrollee on November 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services (A0425 and A0428) provided on July 
10, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says ambulance services used for the 
transportation of a hospital inpatient to another facility for diagnostic tests or special treatment for example is 
considered part of the inpatient admission, and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that transportation, including transportation by 
ambulance, to and from another hospital or freestanding facility to receive specialized diagnostic or therapeutic 
services not available at the facility where the patient is an inpatient is covered by the prospective payment rate. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Specifically, the documentation supports that the 
enrollee was registered inpatient on the billed date of service and that the ambulance services at issue were 
used for the transportation to another facility for diagnostic tests or special treatment. Payment for these 
ambulance services is included in the payment to the facility and is the responsibility of the facility to any 
vendor. Therefore, we decided that the Plan does not have to pay for the ambulance services (A0425 and 
A0428) provided on July 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) (K0554) and 
supplies (K0553). 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says you are not insulin treated with multiple daily administrations. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuous 
glucose monitor (CGM) (K0554) and supplies (K0553).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the middle spinal 
canal. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the required six weeks of physical therapy prior to this request have not been completed. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found there are no red flags, 
such as fracture, weakness, or absent reflex. The x-rays show scoliosis. Absent completion and post-evaluation 
of the already prescribed physical therapy program, the medical necessity of the requested MRI has not been 
established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the middle spinal canal.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cyclobenzaprine 5 mg tablet. 
 
You asked the Plan to pre-approve Cyclobenzaprine. You say that this is medically reasonable and necessary. 
The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cyclobenzaprine 5 mg 
tablet.  
 Benefits for Cyclobenzaprine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 SNF care. You say that admission to an SNF is medically necessary for this 
enrollee The Plan denied your request. The Plan says the criteria for admission to an SNF are not met. The 
enrollee can receive the necessary therapy services in a site of lower acuity, such as long-term 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that the enrollee does not require skilled 
nursing services that require the specialized skill, knowledge and judgement of a skilled professional nurse to 
safely and effectively provide medically necessary and reasonable treatment. The enrollee receives oral 
medications and has stable vital signs. The enrollee does require skilled therapy services which require the 
specialized skill, knowledge and judgement of a qualified therapies; however, the enrollee does not require 
these services on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria 
for an inpatient basis in a skilled nursing facility 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) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa tablets. 
 
You asked the Plan to pre-approve Gemtesa tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Gemtesa tablets are not covered under the enrollee's 
Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa tablets.  
 
Benefits for Gemtesa tablets may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that these lab services are payable by Medicare. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on August 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that bi-level or continuous positive airway pressure 
(BiPAP/CPAP) do not have the capabilities of maintaining adequate respiratory status to avoid further 
hospitalizations. The Plan denied your request. The Plan says the denial of authorization for this device is 
correct, because the enrollee could be treated by BiPAP instead. 
 
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 ventilator. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a ventilator. Our physician reviewer found the enrollee has 
chronic obstructive pulmonary disorder (COPD) and obstructive sleep apnea (OSA) as well as heart failure, 
and was found to have CO2 retention during a hospitalization. The enrollee improved on bi-level positive airway pressure (BiPAP) in the hospital and was using it every night. BiPAP is the appropriate treatment for 
the enrollee, and average volume assure pressure support (AVAPS) can be provided via 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 ventilator have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) angiography scan of the 
heart. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says quantitative calcium scoring is not a covered service and will be denied as not medically 
necessary. 
 
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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee is 
asymptomatic from a cardiovascular standpoint, according to the physician. Overall, there is insufficient 
support in the peer-reviewed literature demonstrating a significant benefit of CT imaging of the heart with 
quantitative evaluation of coronary calcium in guiding optimal management of this patient. As such, CT 
imaging of the heart without contrast material with quantitative evaluation of coronary calcium is considered 
experimental/investigational for the evaluation and management of this patient'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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) angiography scan of the heart.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic testing supplies from a non-preferred brand. 
 
You asked the Plan to pre-approve the non-preferred supplies. The Plan denied your request. The Plan says you 
did not meet the criteria. 
 
Plans must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred. 
 
 
 We looked at the file and the rules. The requested diabetic testing supplies is not a preferred brand. The Plan 
has preferred brands available. There is no indication that you are unable to use on of the Plans preferred 
brands. We found no exception that would require the Plan to pre-approve a non-preferred brand. Therefore, 
we decided that the Plan does not have to pre-approve diabetic testing supplies from a non-preferred brand.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on December 9, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 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 71045 
is a column II code to column I code 71046. 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 imaging services provided to the enrollee on December 9, 2021.