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

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on October 18, 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 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. Therefore, we decided that the Plan does not have to pay for a 
comprehensive periodontal evaluation (D0180) provided on October 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart. 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is needed to determine the enrollee's 
cardiovascular risk. The Plan denied your request. The Plan says the requested CT scan is for screening 
purposes and the enrollee has no symptoms. 
 
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 scan. Our reviewer says that the 
CT scan of the heart is not medically necessary. Our physician reviewer found that the enrollee has a smoking 
history and hyperlipidemia, resistant to taking cholesterol-lowering medications. Their low-density lipoproteins 
are 230. A coronary artery calcium score CT was ordered to convince them to take medication. However, the 
enrollee is already at a high risk for cardiovascular events based on his cholesterol levels and the treatment plan 
would not change regardless of the results of a CT scan which is more appropriate for those at an intermediate 
risk level. 
 
  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 scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the heart.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tooth extraction. 
 
You asked the Plan to pre-approve the extraction. You say that that you feel the tooth extraction is medically 
necessary. The Plan denied your request. The Plan says you do not meet the Medicare guidelines for coverage 
of a dental tooth extraction. 
 
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 
covered under the medical benefit. However, you can receive this service under your POS benefit and submit 
the claim for reimbursement.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an acute inpatient hospital stay provided 
from October 6, 2022, to October 8, 2022. 
 
You asked the Plan to reduce the copayment for a hospital stay. You say that you stayed in a hospital located in 
the Philippines, which has relatively lower rates, and should not have to pay the whole copayment. 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 $225 
copayment per day for days 1 to 5 of inpatient hospital care.  
 
You have been asked to pay a total of a $450 copayment per day for days 1 to 5 of inpatient hospital care ($225 
copayments per day x 2 days=$450). This item/service falls within the inpatient hospital stay benefit category. 
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 reduce the copayment for an acute inpatient hospital stay provided from October 6, 
2022, to October 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says you do not meet the criteria to be eligible for SSBCI 
benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SSBCI benefits have not been met. Specifically, we have confirmed that you do not meet the 
intensive care management criteria listed in the EOC, which is 2 or more inpatient admission in the last 60 
days, or 3 or more emergency room visits in the last 60 days. Therefore, we decided that the Plan does not have 
to pre-approve the SSBCI benefits.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve an inpatient hospital admission. The Plan denied your request. The Plan 
says that this request cannot be approved. 
 
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 an inpatient hospital admission. Our 
reviewer says that the documentation supports that the criteria for inpatient coverage are met in this case. Our 
physician reviewer found the enrollee presented to the emergency department on February 1, 2023, with 
confusion and elevated blood pressure. The enrollee was evaluated and admitted to the medical floor. Our 
reviewer found that the enrollee required changes in their medical regimen with the possibility of initiating 
dialysis. The enrollee will require a skilled nursing facility placement due to their inability to care for themself. 
Our physician reviewer also found that the record did show that the admitting physician reasonably expected 
that the enrollee's necessary hospital care would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient hospital admission have been met. Therefore, we decided that the 
Plan has to pre-approve an inpatient hospital admission.  
 
  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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee has no 
documented complex medical needs and medical condition has stabilized. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical or occupational therapy, and an intensive rehabilitation therapy program.  
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95811). 
 
You asked the Plan to pre-approve a sleep study. You say that the requested services is necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for a repeat sleep study. 
 
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 a sleep study. 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 severe obstructive sleep apnea and has been on continuous positive airway 
pressure (CPAP) since 2018. The enrollee was recently seen for a routine follow-up, and a repeat split-night 
polysomnogram was ordered, apparently because the enrollee is eligible for a replacement CPAP device. 
According to the progress note, the enrollee is having no issues with the CPAP, usage is 100%, and residual 
apneahypopnea index (AHI) is less than 2. There does not appear to be a medical need for a repeat 
polysomnogram. 
 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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95811).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeletal knee-shin system, single axis, fluid 
swing and stance phase control (L5828), endoskeletal, knee-shin system, stance flexion feature (L5845), 
endoskeletal knee-shin system, fluid stance extension, dampening feature (L5848), microprocessor control 
feature, swing and stance phase, includes electronic sensor(s) (L5856), multi-axial rotation unit (L5986), and 
flex-walk system or equal (L5981). 
 
You asked the Plan to pre-approve a fluid swing and stance phase control, stance flexion feature, fluid stance 
extension, microprocessor control feature, multi-axial rotation unit, and flex-walk system or equal. You say 
that the enrollee meets the Medicare criteria for a Microprocessor knee and Flex-walk system foot based on 
history, current condition, and ability to use the recommended device. You also say that the requested 
prosthetic components are medically necessary to meet this enrollee's basic needs. The Plan denied your 
request. The Plan says the requested prosthetic parts exceed the enrollee's need. 
 
The Plan follows Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
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 fluid swing and stance phase control, 
stance flexion feature, fluid stance extension, microprocessor control feature, multi-axial rotation unit, and flex-
walk system or equal. Our reviewer says that this request is not medically reasonable and necessary for the 
enrollee. Our physician reviewer found the enrollee does not require a microprocessor prosthesis. The 
microprocessor is for advanced activities. Our reviewer found that the enrollee is a basic K3 ambulator at best. 
Our physician reviewer also found that there is no indication the enrollee requires the advanced technology of a 
microprocessor to maintain function or community ambulate. 
 
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 fluid swing and stance phase control, stance flexion feature, fluid stance 
extension, microprocessor control feature, multi-axial rotation unit, and flex-walk system or equal have not 
been met. Therefore, we decided that the Plan does not have to pre-approve an endoskeletal knee-shin system, 
single axis, fluid swing and stance phase control (L5828), endoskeletal, knee-shin system, stance flexion 
feature (L5845), endoskeletal knee-shin system, fluid stance extension, dampening feature (L5848), 
microprocessor control feature, swing and stance phase, includes electronic sensor(s) (L5856), multi-axial 
rotation unit (L5986), and flex-walk system or equal (L5981).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical cancer screening (G0101), provided on 
September 7, 2022. 
 
You asked the Plan to pay for the cervical cancer screening. You say that the service was medically necessary. 
The Plan denied your request. The Plan says the maximum frequency for this service has been exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 cervical cancer screening have not been met. Specifically, you have 
exhausted the allowed amount for this service. Therefore, we decided that the Plan does not have to pay for the 
cervical cancer screening (G0101), provided on September 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for breast cancer screening provided on 
September 14, 2022. 
 
You asked the Plan to waive the cost share for breast cancer screening. You say that you disagree with the cost 
share 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. Your 
contract with the Plan says that there is a $800 deductible which applies to breast cancer screening.  
 
The item or service you asked the Plan to waive the cost share for falls within the breast cancer screening 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $800 
deductible which applies to breast cancer screening. You are being asked to pay $127.39 towards you 
deductible. This cost sharing is a contractual obligation that had not been met at the time breast cancer 
screening was received on September 14, 2022. Therefore, we decided that the Plan does not have to waive the 
cost share for breast cancer screening provided on September 14, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2740), and a core build-up (D2950) for tooth #2. 
 
You asked the Plan to pre-approve a crown, and a core build-up. You say that this dental work is medically 
necessary. The Plan denied your request. The Plan says that the medical criteria for these dental services have 
not been met. 
 
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, and 
a core build-up 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, and a core build-up. Our 
physician reviewer found the documentation provided meets the criteria for coverage for a core buildup and 
crown restoration for tooth #2. 
 
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, and a core build-up have been met. Therefore, we decided that the 
Plan has to pre-approve a crown (D2740), and a core build-up (D2950) for tooth #2.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 23, 
2022. 
 You asked the Plan to pay for procedure code 70450. 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 70450 is bundled into 
payment for code 70496. 
 
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 procedure code 70450 billed for date of service October 23, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
device (MyoPro Motion G) (L8702). 
 
You asked the Plan to pre-approve MyoPro Motion G device. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device is not medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve MyoPro Motion G device. Our 
reviewer says that the requested MyoPro Motion G device is not considered medically reasonable and 
necessary in this case. Our physician reviewer found current clinical guidelines for adult stroke rehabilitation 
and recovery designate robotic therapy to be of "uncertain utility compared with dose-matched conventional 
upper limb exercise therapies" with unproven benefit in the home environment. Although records from the 
device manufacturer/vendor argue medical necessity of the requested device, records from the enrollee's actual 
treating provider do not clarify why the requested device is the most appropriate treatment for the enrollee's 
condition. Therefore, the reviewer found that the requested device 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 MyoPro Motion G device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a powered upper extremity range of motion assist device (MyoPro Motion 
G) (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-home ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that this was denied because it was to be used in the 
"Bi-level Mode" only. You also say that the physician order does not indicate that the requested item will only 
be used in Bi-Pap mode only. The Plan denied your request. The Plan says the requested item is not medically 
necessary. 
 
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 ventilator. Our reviewer says that the 
requested ventilator is not medically necessary. Our physician reviewer found the provided documentation does 
not indicate evidence of any pulmonary function tests to confirm the severity of the chronic obstructive 
pulmonary disease (COPD), and no arterial blood gas (ABG) done while stable to document chronic carbon dioxide retention. The reviewer found that in the absence of severe COPD with chronic carbon dioxide 
retention the requested ventilator 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an in-home ventilator (E0466).