Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic colonoscopy (45378).  
You asked the Plan to pre-approve the testing. You say that the enrollee's previous colonoscopy in 2018 
resulted in a 3 millimeter (mm) hyperplastic polyp being resected. You say that the prevailing guidelines 
recommend a repeat colonoscopy after five years. You also say that the enrollee's health situation has evolved 
since then, leading to the emergence of new medical concerns, including diverticulitis. The Plan denied your 
request. The Plan says this 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 the testing. Our reviewer says that the 
requested colonoscopy is not considered medically reasonable and necessary in this case. Our physician 
reviewer found while diverticulitis can prompt screening for colorectal cancer, the enrollee already had up to 
date colorectal cancer screening. A distal hyperplastic polyp is not an adenoma, and thus a time interval of 10 
years should have been recommended. Therefore, the reviewer found that the requested colonoscopy is not 
medically reasonable or necessary at this time as the enrollee is not considered to be at high risk for colorectal 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a diagnostic colonoscopy (45378).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the requested SNF stay is in the enrollee's best 
interest. The Plan denied your request. The Plan says a SNF stay is 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 and/or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve GELSYN-3. 
 
You asked the Plan to pre-approve GELSYN-3. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 GELSYN-3. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the elements of the coverage criteria 
are satisfied.  The requested service is recommended. The case file indicates that the plan has approved the 
requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of GELSYN-3 have been met. Therefore, we decided that the Plan has to pre-
approve GELSYN-3.  
 
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 portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you are unable to get out your 
home due to not having the portable oxygen concentrator, and you have had to delay numerous appointments 
and trips. The Plan denied your request. The Plan says Medicare does not pay for duplicate equipment that 
performs the same function as previously provided equipment and does not cover additional equipment for use 
outside the home. The Plan also says that you were previously provided with a home oxygen system including 
portable oxygen tanks for oxygen needs within the home, and there is no documentation that this equipment is 
not satisfying your oxygen needs within the home. 
 The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare rules also say if DME serves the same purpose as equipment 
already available to an enrollee, it is not considered reasonable and necessary. 
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. The file also shows that you have a home 
oxygen system including portable oxygen tanks. The home oxygen system serves the same purpose as the 
requested portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a 
portable oxygen concentrator (E1392).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network inpatient hospital stay 
provided from February 27, 2023, to March 7, 2023. 
 
You asked the Plan to waive the copayment for an in-network inpatient hospital stay. You say that as this 
inpatient stay happened one right after the other, you should only have to pay a $123 copayment for the 
continuation. 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 $123 
copayment per day, for days 1-7 for inpatient hospital services.  
 
You were in the hospital for 7 days, resulting in a $861 total copayment (7 x $123 = $861). 
 You have been asked to pay a $861 copayment per day, for inpatient hospital services. This item/service falls 
within the inpatient hospital services 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 waive the copayment for 
an in-network inpatient hospital stay provided from February 27, 2023, to March 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Transcutaneous Electrical Nerve Stimulation (TENS) 
device. 
 
You asked the Plan to pre-approve a TENS device. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that TENS therapy for Chronic Low Back Pain (CLBP) 
will be denied as not reasonable and 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 a TENS device. Our reviewer says that 
the enrollee does not need this item. Our physician reviewer found the enrollee has chronic low back pain and 
is not enrolled in a clinical study. 
 
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 TENS device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Transcutaneous Electrical Nerve Stimulation (TENS) device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anti-reflective coating (V2750), scratch resistant coating 
(V2760), progressive lenses (V2781), and polycarbonate lenses (V2784) provided on April 10, 2023. 
 
You asked the Plan to pay for anti-reflective coating (V2750), scratch resistant coating (V2760), progressive 
lenses (V2781), and polycarbonate lenses (V2784). You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says because the provider is out-of-network with your plan and because 
there is no coverage when services are rendered by a non-participating provider. 
 
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 these services when the services are obtained through an in-network optical provider. 
 
We looked at the file and the Plan's rules. The Plan rules say any benefits received at a non-network optical 
provider are excluded from the Plan. Based on this information, we decided that the Plan's rules for coverage of 
anti-reflective coating (V2750), scratch resistant coating (V2760), progressive lenses (V2781), and 
polycarbonate lenses (V2784) have not been met. Therefore, we decided that the Plan does not have to pay for 
anti-reflective coating (V2750), scratch resistant coating (V2760), progressive lenses (V2781), and 
polycarbonate lenses (V2784) provided on April 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve private duty / independent nursing service(s) (T1000). 
 You asked the Plan to pre-approve private duty / independent nursing service(s). You say that the enrollee was 
able to acquire this benefit last year, and you would like to know why it is not covered this year. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 private duty / independent nursing 
service(s). Our reviewer says that the services are not medically reasonable and necessary. Our physician 
reviewer found Medicare does provide intermittent nursing for skilled nursing needs but does not provide 
private duty nursing 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 private duty / independent nursing service(s) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve private duty / independent nursing service(s) (T1000).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis 
(D1110), and complete series of intraoral x-rays (D0210) provided on March 20, 2023, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the dental 
services were received from an OON provider and are not covered by your supplemental 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. 
 
 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the comprehensive oral evaluation (D0150), prophylaxis (D1110), and complete series of intraoral x-
rays (D0210) provided on March 20, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral exam (D0120) and the intraoral radiographic 
images (D0220 and D0230) provided on June 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied dental services. 
The Plan denied your request. The Plan says your benefit for the requested items or services 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 the Plan paid for a limited oral evaluation (D0140) and the intraoral radiographic images (D0220 and 
D0230) on January 3, 2023; therefore, your benefit for the requested items or services was exhausted on the 
date of service of January 3, 2023. Therefore, we decided that the Plan does not have to pay for a periodic oral 
exam (D0120) and the intraoral radiographic images (D0220 and D0230) provided on June 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0835). 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair. You say that you are submitting an 
appeal on behalf of the client so the client can get the equipment/devices they need to help make their daily 
lives for the better. The Plan denied your request. The Plan says the requested chair is to be used outside of the 
home. The Plan also says that Medicare covers power wheelchairs only for use in the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a group 2 standard power wheelchair (K0835).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the photodynamic therapy, and the topical 
gel provided on May 11, 2023. 
 
You asked the Plan to waive the cost sharing for the photodynamic therapy, and the topical gel. You say that 
you were told that these services would be covered. 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 20% 
coinsurance for chemotherapy drugs, infusion drugs, and all other drugs covered under Medicare Part B, and a 
$40 copayment for office visits to specialists. 
 
You have been asked to pay a $131.05 coinsurance for the topical gel ($655.25 allowed amount x .20 = 
$131.05). This item/service falls within the Medicare Part B prescription drugs benefit category. You have also 
been asked to pay a $40 copayment for the photodynamic therapy. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 waive the cost sharing for the photodynamic therapy, and the topical gel provided on May 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481, 87653, 87798, and 87801 billed for 
date of service January 25, 2023. 
 
You asked the Plan to pay for the billed services. You say that the results substantiate the test performed. The 
Plan denied your request. The Plan says payment for code 87481, 87653, 87798 is bundled into payment for 
code 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
The file shows that a urinary tract infection panel was provided. In this case, we have confirmed that code 
87481, 87653, 87798 is a column II code to column I code 87801. The records do not show that the services 
billed with the XU modifier were unusual non-overlapping components of the main service. The panel testing 
was not billed with a single code as required. 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 87481, 87653, 87798, 
and 87801 billed for date of service January 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical assistant services provided on February 1, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the assistant is 
not eligible for separate reimbursement. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
 We looked at the file and the rules. In this case, the record does not show that the provider of the surgical 
assistant service was a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant 
services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not 
have to pay for the surgical assistant services provided on February 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation (64624). 
 
You asked the Plan to pre-approve genicular radiofrequency ablation . You say that the service is medically 
necessary. The Plan denied your request. The Plan says this service is considered experimental. 
 
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 genicular radiofrequency ablation . Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this service is considered experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular radiofrequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve genicular radiofrequency ablation (64624).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954) 
provided on April 27, 2023. 
 
You asked the Plan to pay for the prefabricated post and core. You say that you would like the Plan to pay for 
100% of the cost for the entire crown, including the necessary items that should be part of the procedure. The 
Plan denied your request. The Plan says this service is not a covered expense under your Dental plan. The Plan 
also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility. 
 
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 
prefabricated post and core in addition to crown (D2954) provided on April 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the abdomen and pelvis computed 
tomography (CT) scan provided on April 19, 2023, and the thorax computed tomography (CT) scan provided 
on April 21, 2023. 
 
You asked the Plan to waive the copayment for the computed tomography (CT) scans. You say that you cannot 
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 $350 
copayment per day for other Medicare-covered diagnostic radiology services, including computed tomography 
(CT) scans. 
 You have been asked to pay a $350 copayment for the abdomen and pelvis computed tomography (CT) scan. 
You have also been asked to pay a $125.95 for the thorax computed tomography (CT) scan because the 
allowed amount for this service is less than the $350 copayment. These items/services fall within the outpatient 
diagnostic tests and therapeutic services and supplies 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 waive the 
copayment for the abdomen and pelvis computed tomography (CT) scan provided on April 19, 2023, and the 
thorax computed tomography (CT) scan provided on April 21, 2023.