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

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. The Plan denied your request. The Plan says a 
home ventilator is not medically necessary for this patient because their needs can be met with an alternative 
device such as a BiPAP device with average volume-assured pressure support (AVAPS).  
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy 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 home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
does not have substantial evidence to indicate the requirement for a home ventilator or intelligent volume-
assured pressure support (IVAPS) therapy. Also, there is no arterial blood gas, but an end-tidal carbon dioxide 
was provided. The best practice would dictate starting with BiPAP therapy to assess response with or without 
AVAPS if needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental visit to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the dental services. You say that you have been using the same dentist for 
years and you would like to finish the service with the same provider. The Plan denied your request. The Plan 
says dental services from an out-of-network provider are not covered by your supplemental benefits. Also, 
there are multiple in-network provider in your service area. 
 
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. 
 
  You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, dental 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 pre-approve a dental visit to be 
provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the heart with calcium scoring. 
 
You asked the Plan to pre-approve a CT scan of the heart with calcium scoring. You say that the enrollee has a 
significant family history of early coronary arty disease. You say that the enrollee has been experiencing 
symptoms of dyspnea and atypical chest pain. The Plan denied your request. The Plan says a CT scan of the 
heart with calcium scoring is 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 a CT scan of the heart with calcium 
scoring. Our reviewer says that a CT scan of the heart with calcium scoring is not medically necessary. Our 
physician reviewer found that 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 the enrollee. As such, CT imaging of the heart without contrast material with 
quantitative evaluation of coronary calcium is considered experimental and investigational for the evaluation 
and management of the enrollee'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 a CT scan of the heart with calcium scoring have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a CT scan of the heart with calcium scoring.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested items has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items has been previously exhausted. Specifically, the Plans contract 
states that dentures indicated by codes (D5110-D5286), are covered once per arch, every 60 months.   
 
 
 
 
 
You previously received a complete upper denture (D5110) on October 20, 2022 and a lower partial denture 
(D5226) on November 22, 2022, less than 60 months prior, which were paid for by the Plan. Therefore, you 
have exhausted the allowable benefit for the requested items in this case. Therefore, we decided that the Plan 
does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000).  
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit for the enrollee's 
condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics (L3000).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 additional skilled nursing visits. You asked the Plan to 
pre-approve home health services. You say that you would like reconsideration based on the records submitted.  
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
clinical documentation does not specify any acute clinical status changes, changes in plan of care or 
medications, or complex wounds. Thus, the records do not show that 3 additional home health skilled nursing 
visits are required to effectively provide treatment, care, and/or services to improve the enrollee's condition, or 
to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 3 additional skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services. 
 
You asked the Plan to pre-approve acupuncture services. You say that you have chronic pulmonary fibrosis, 
and your lung doctor advised you that the only thing that they can do is to put you on a pill which is extremely 
expensive and that it will only help to control the progression of the disease, which can extend your life for 
another two or three years. The Plan denied your request. The Plan says acupuncture is only covered for 
chronic low back pain. 
 
  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.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you have chronic pulmonary fibrosis, and 
acupuncture is only covered for chronic low back pain. Therefore, we decided that the Plan does not have to 
pre-approve acupuncture services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve branch injections. 
 
You asked the Plan to pre-approve genicular nerve branch injections. You say that this is medically necessary. 
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 genicular nerve branch injections. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are 
considered investigational and not medically necessary for the treatment of chronic knee pain. The review has 
determined that the requested genicular nerve blocks are 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 genicular nerve branch injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve genicular nerve branch injections.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services without transport received on March 23, 
2023. 
 
You asked the Plan to pay for ambulance services without transport. You say that the services were medically 
necessary. The Plan denied your request. The Plan says without transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 23, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services without transport received on 
March 23, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 ground transportation trips. 
 
You asked the Plan to pre-approve the transportation trips. You say that the services are medically necessary 
for you to get to your appointments. The Plan denied your request. The Plan says there is no documented 
reason why another form of transportation could not be used. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of the transportation trips have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 2 ground transportation trips.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation services provided on April 12, 2023. 
 
You asked the Plan to pay for transportation services. You say that the services were medically necessary, and 
a taxi was the quickest way for you to get to the hospital. The Plan denied your request. The Plan says the 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of transportation services have not been met. Therefore, we decided that 
the Plan does not have to pay for transportation services provided on April 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization (PAE). 
 
You asked the Plan to pre-approve PAE. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this is not recommended outside of the context of a clinical trial. 
 
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 PAE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered an experimental technique. Very limited studies have demonstrated possible 
short-term safety and efficacy and guidelines do not recommend this procedure outside of a clinical trial 
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 PAE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve prostate artery embolization (PAE).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
  You asked the Plan to pre-approve a home ventilator. You say that you would like this patient's non-invasive 
ventilator (NIV) to be approved so that you can keep them free from emergency room visits, additional 
admissions, and potentially death if left untreated. The Plan denied your request. The Plan says the request for a 
home mechanical ventilator set in average volume-assured pressure support (AVAPS) mode with Auto-
expiratory positive airway pressure (EPAP) that could be delivered by BiPAP is not covered. 
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy 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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found this patient has COPD, with 
pulmonary function tests in 2021 showing a forced expiratory volume in the first second (FEV1) of 51% of 
predicted with air trapping. The patient was hospitalized in October 2023 with COPD exacerbation and 
congestive heart failure.  An arterial blood gas done while acutely ill showed mild carbon dioxide (CO2) 
retention with a partial pressure of carbon dioxide of 55. Our reviewer found that there is no diagnosis of 
thoracic restrictive disease or neuromuscular disease. There is no arterial blood gas (ABG) done while stable to 
document chronic CO2 retention. The patient's lung function in 2021 did not appear severe enough to cause 
chronic CO2 retention. Our physician reviewer also found that if the patient does have chronic CO2 retention, 
they may benefit from BiPAP with AVAPS during sleep as an outpatient. The records do not show this has 
been tried and failed as an outpatient. Medicare does not cover a home ventilator when used at settings that can 
be provided with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
  You asked the Plan to pre-approve a home ventilator. You say that without non-invasive ventilatory therapy, 
the patient is at high risk for hospital readmission and potentially life-threatening exacerbations. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in targeted tidal volume, 
volume-assured pressure support (TTV-VAPS) mode with Auto-expiratory positive airway pressure (EPAP) 
that could be delivered by BiPAP is not covered. 
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy 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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found this patient has severe obesity, 
suspected obstructive sleep apnea, and obesity hypoventilation syndrome. There is no diagnosis of COPD, 
restrictive thoracic disease, or neuromuscular disease. Our reviewer found that the patient was hospitalized in 
October 2023 with exacerbation of congestive heart failure, and improved with treatment. Arterial blood gases 
were consistent with acute on chronic hypercarbic respiratory failure. Our physician reviewer also found that 
this patient may benefit from BiPAP during sleep as an outpatient, but the records do not show this has been 
tried and failed as an outpatient. Medicare does not cover a home ventilator when used at settings that can be 
provided with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the self-administered drugs. 
 
You asked the Plan to pre-approve the medication. The Plan denied your request. The Plan says the medication 
is not covered as a medical benefit under the Plan. 
 
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 the self-administered drugs.   
Benefits for the medication 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia-first 15 minutes 
(D9222) and deep sedation/general anesthesia-each subsequent 15 minute increment (D9223). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says dental services are not payable when rendered by an 
out-of-network provider.  
 
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 services are not among 
those covered under this benefit. Additionally, dental services rendered by an out-of-network provider are not 
covered under the supplemental dental policy. Therefore, we decided that the Plan does not have to pre-
approve deep sedation/general anesthesia-first 15 minutes (D9222) and deep sedation/general anesthesia-each 
subsequent 15 minute increment (D9223).
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. You say that the enrollee requires IRF services. The Plan denied 
your request. The Plan says the enrollee does not meet the requirements for an IRF admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found The complexity of the enrollee's nursing, medical, and rehabilitation needs can be 
provided in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical 
therapy and occupational therapy, but this can be provided in a lower level of care. There is documentation that 
there is a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF, but the services required can be provided at a 
lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.