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

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested ventilator is medically 
necessary. The Plan denied your request. The Plan says the requested ventilator does not meet criteria. 
 
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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have Parkinson's disease, which 
does not typically cause ventilatory failure. You have very mild CO2 retention on an ABG but the 
circumstances were not provided, and the full results of the ABG were not provided. There is no ABG done as 
an outpatient while stable to document chronic CO2 retention. There are no pulmonary function tests or tests of 
respiratory muscle strength, such as maximum mouth pressures. There is no diagnosis of COPD, thoracic 
restrictive disease, or neuromuscular disease-causing diaphragmatic dysfunction. Even if you have chronic 
CO2 retention, the need could be met with bipap. There is no documented failure of bipap in the home 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 a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided to the enrollee on May 4, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that the enrollee's physician sent the specimen to be 
processed. The Plan denied your request. The Plan says that they require enrollees to get care from 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 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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 pathology services provided to the enrollee on 
May 4, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you under the Flex Benefit for routine transportation 
services provided from February 11, 2022, through March 11, 2022. 
 
You asked the Plan to reimburse you under the Flex Benefit for routine transportation. You say that there were 
circumstances which resulted in a need for a sleep study and cardiology care. You say that you were under the 
impression that the Flex Benefit would continue through 2022. The Plan denied your request. The Plan says the 
Flex Benefit was removed from your Plans benefit package effective January 1, 2022. 
 
The Plan contract does not cover the Flex Benefit effective January 1, 2022. 
 
We looked at the file and the Plans rules. The file shows that the Plan removed the Flex Benefit from your 
Plans benefit package effective January 1, 2022. Therefore, we decided that the Plan does not have to 
reimburse you under the Flex Benefit for routine transportation services provided from February 11, 2022, 
through March 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on December 24, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the ordered testing was not medically 
reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing services are subject to the criteria 
listed 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 pay for the genetic testing. Our reviewer says that 
the requested testing was not medically reasonable and necessary. Our physician reviewer found that the 
enrollee is an 82-year-old man with stage III adenocarcinoma of the pancreas. A Whipple surgical procedure 
was performed on September 7, 2021, and a computed tomography (CT) scan on November 10, 2021, revealed 
several hepatic metastases. The Medical Oncology Progress Note dated December 7, 2021, documents that the 
enrollees prognosis is poor, and palliative chemotherapy versus best supportive care were his options. 
Chemotherapy with gemcitabine was started on December 2, 2021.   
 
The documentation does not support that the coverage criteria for the Tempus genetic testing in this case met 
the NDC criteria for Next Generation Sequencing. This genetic testing does not have FDA approval or 
clearance as a companion in vitro diagnostic, and an FDA approved or cleared indication for use in this 
enrollees 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 the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the genetic testing services provided on December 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 very heavy duty, single power option, 
sling/solid seat/back wheelchair and accessories (K0839, E1002, K0108, E2310). 
 
You asked the Plan to pre-approve a group 2 heavy duty power wheelchair. You say that this is medically 
necessary. The Plan denied your request. The Plan says during your office visit on June 30, 2022, your weight 
was documented as 332 pounds. The Plan also says you do not meet criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that a power operated vehicle (POV) can be covered 
if the beneficiarys weight is less than or equal to the weight capacity of the POV that is provided and greater 
than or equal to 95% of the weight capacity of the next lower weight class. A Heavy Duty POV is covered for a 
beneficiary weighing 285  450 pounds. 
 
We looked at the file and Medicare rules. The file indicates your weight does not fall within the required 
weight range. Therefore, we decided that the Plan does not have to pre-approve a group 2 very heavy duty, 
single power option, sling/solid seat/back wheelchair and accessories (K0839, E1002, K0108, E2310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full amount for a resin-based composite filling on tooth #3 
(D2393) provided on February 10, 2022. 
 
You asked the Plan to pay the full amount for a resin-based filling. You say that you had a broken tooth, and 
the dentist used a resin-based filling instead of amalgam base to fix the tooth. The Plan denied your request. 
The Plan says if a method of treatment is more costly than is customarily provided, benefits will be paid on the least costly method of treatment, and you will be responsible for the remaining balance. The Plan also says you 
have been charged the correct cost sharing amount. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a resin-based 
filling (D2393) when the services are medically necessary and reasonable. The Plan will pay for the least costly 
treatment that will produce a satisfactory result. The Plan rules say you are responsible for 50% coinsurance of 
the allowed amount for the least costly treatment. The Plan rules also say you are responsible for the difference 
between the least costly treatment and the treatment you received. 
 
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 a resin-based filling. Our reviewer says that 
the criteria for coverage has not been met for a resin-based composite filling. Our physician reviewer found, in 
this case, the amalgam filling is expected to produce a professionally satisfactory result. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
you have been charged the correct cost sharing amount. You have been asked to pay 50% coinsurance of the 
allowed amount for the least costly treatment ($156 amalgam allowed amount x 50% coinsurance = $78). You 
have also been asked to pay the difference between the least costly treatment and the treatment you received 
($220 resin allowed amount - $156 amalgam allowed amount = $64). Your total responsibility is $142 ($78 + 
$64 = $142). Therefore, we decided that the Plan does not have to pay the full amount for a resin-based 
composite filling on tooth #3 (D2393) provided on February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pathology testing coded as 81206 and 81292 
provided July 7, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you request reconsideration of this 
determination and coverage of the Tempus Gene Panel test at the in-network benefit level. The Plan denied 
your request. The Plan says doesn't meet Medicare NCD/LCD criteria. Diagnosis code does not substantiate 
service. 
 
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 81206 is BCR/ABL1 (t(9;22)) (eg, chronic myelogenous 
leukemia) translocation analysis; major breakpoint, qualitative or quantitative and 81292 is MLH1 (mutL 
homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch 
syndrome) gene analysis; full sequence analysis. 
 
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 the laboratory services. Our reviewer says that the records do 
not meet the criteria for the laboratory services. Our reviewer found for CPT codes 81206 and 81292 the 
documentation submitted was reviewed and does not meet the criteria. The laboratory report contains 
laboratory assays of two or more genes in parallel. Per Medicare "A panel constitutes a single procedural 
service, and one CPT code would be submitted for the panel". In this case, services were reported incorrectly. 
 
We looked at this coder's review, the file, and Medicare rules. 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 molecular pathology testing coded as 81206 and 81292 provided July 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a white glass with high gold content crown for tooth #3. 
 
You asked the Plan to pre-approve crown. You say that you are requesting this crown. The Plan denied your 
request. The Plan says the requested crown is not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers crown when 
the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that you do 
not meet the criteria for the requested crown. Our physician reviewer found the supplied records do not contain 
a readable X-Ray of tooth #3. As there is no method to assess the amount of involved structure of tooth #3 without a clear X-Ray of the tooth, or to assess the amount of bone support which is required to maintain a 
tooth in the arch, there can be no finding of medical necessity for the requested crown. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of crown have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a white glass with high gold content crown for tooth #3.
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 enrollee was approved for a 
reverse left total shoulder arthroplasty and will need inpatient admission after surgery. The Plan denied your 
request. The Plan says there is no documentation provided to support the expectation the enrollee will require a 
greater than 2 midnight stay. 
 
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 the enrollee is approved for a reverse left total shoulder arthroplasty. The 
record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 
or more 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inhalation of nitrous oxide (D9230) provided from 
February 8, 2022, to March 22, 2022.  
 
You asked the Plan to pay for nitrous oxide. You say that these are covered services per your benefit manual, 
but they keep getting denied. The Plan denied your request. The Plan says the inhalation of nitrous oxide 
(D9230) is covered as needed with covered procedures. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the inhalation 
of nitrous oxide (D9230) as needed with covered procedures. 
 
We looked at this case file, the Plan's rules, and Medicare rules. According to the EOC, the inhalation of 
nitrous oxide is only covered as needed with covered procedures. The record shows the extractions that were 
performed on February 8, 2022, February 22, 2022, March 10, 2022, and March 22, 2022, were denied. 
Therefore, since the extractions were denied the inhalation of nitrous oxide is not covered. We decided that the 
Plan does not have to pay for the inhalation of nitrous oxide (D9230) provided from February 8, 2022, to 
March 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an open sacral iliac joint fusion procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says the clinical documentation presented does not demonstrate any 
evidence of sacroiliac joint instability, fracture, or tumor presence. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is no 
documented sacral iliac (SI) joint instability, fracture or lesion. SI joint fusion for degenerative back pain 
without instability remains experimental. Our physician reviewer found that the enrollee's condition does 
not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an open sacral iliac joint fusion procedure for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown - porcelain/ceramic (D2740) for tooth #25. 
 
You asked the Plan to pre-approve a crown. You say that the patient could fracture the tooth if they do not 
receive a crown. The Plan denied your request. The Plan says that the crown is not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a crown when 
the services are medically necessary and reasonable. 
 
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 crown. Our reviewer says that the 
service is medically necessary. Our physician reviewer found that due to the amount of coronal breakdown of 
tooth #25, a crown restoration is medically reasonable and necessary to prevent fracture. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have been met. Therefore, we decided that the Plan has to pre-approve 
a crown - porcelain/ceramic (D2740) for tooth #25.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the collection and application of autologous blood 
concentrate (D7921), an implant supported crown (D6067), an implant supported crown (D6065), and a bone 
graft (D6104), provided by participating providers on November 3, 2021, to February 16, 2021. 
 
You asked the Plan to pay for the collection and application of autologous blood concentrate, an implant 
supported crown, an implant supported crown, and a bone graft. You say that you would like the Plan to pay 
for this. The Plan denied your request. The Plan says the rendered services are not covered. 
 
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 collection and application of autologous blood concentrate (D7921), an implant supported crown (D6067), an 
implant supported crown (D6065), and a bone graft (D6104), provided by participating providers November 3, 
2021, to February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided on June 1, 2021, a 
comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided September 27, 2021, resin-
based composite fillings (D2392, D2330) provided on November 5, 2021, resin-based composite fillings 
(D2335, D2332) provided on November 12, 2021, and a limited oral evaluation (D0140) provided on 
December 30, 2021. 
 
You asked the Plan to pay for prophylaxis, x-ray, fillings, and evaluations.. You say that due to your medical 
history you would like these services covered under your medical benefit. The Plan denied your request. The 
Plan says your annual $500 allowance for dental services has been exhausted. The Plan also says that these 
services are considered dental in nature. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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 once the $500 allowance has been met. Therefore, we decided that the 
Plan does not have to pay for prophylaxis (D1110) provided on June 1, 2021, a comprehensive oral evaluation 
(D0150) and panoramic x-ray (D0330) provided September 27, 2021, resin-based composite fillings (D2392, 
D2330) provided on November 5, 2021, resin-based composite fillings (D2335, D2332) provided on November 
12, 2021, and a limited oral evaluation (D0140) provided on December 30, 2021.