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

 
We decided that the Plan does not have to pre-approve tomographic (SPECT) myocardial perfusion imaging.  
 
You asked the Plan to pre-approve tomographic (SPECT) myocardial perfusion imaging. You say that 
tomographic (SPECT) myocardial perfusion imaging is medically necessary. The Plan denied your request. 
The Plan says the requested tomographic (SPECT) myocardial perfusion imaging does not meet the Medicare 
LCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that tomographic (SPECT) myocardial perfusion imaging 
is covered when the criteria listed in the Medicare rules section of this decision are met. 
 
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 tomographic (SPECT) myocardial 
perfusion imaging. Our reviewer says that the requested tomographic (SPECT) myocardial perfusion imaging 
is not considered medically reasonable and necessary in this case. Our physician reviewer found the stress 
SPECT test is not indicated with no cardiac symptoms, good exercise capacity, and right bundle branch block 
(RBBB). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of tomographic (SPECT) myocardial perfusion imaging have not been met. 
Therefore, we decided that the Plan does not have to pre-approve tomographic (SPECT) myocardial perfusion 
imaging.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from July 24, 2023, through 
July 29, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary.  
 
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 pay for these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee presented to the emergency department (ED) on July 24, 2023 with a one week history 
of hematuria. He was evaluated and had an elevated white blood cell count to 15.8 and an abnormal urinalysis. 
He was treated for a urinary tract infection (UTI) one week prior. He was admitted with a complicated UTI 
requiring intravenous (IV) antibiotics (Meropenum), and IV fluids. He was admitted. His condition stabilized 
and improved and he was considered medically stable for discharge on July 29, 2023. The review indicates that 
the record showed that at the time of the inpatient admission it was reasonable for the admitting physician to 
expect that the enrollees necessary hospital care (including earlier ED and/or observation care) would span 
two midnights with supporting documentation of the enrollees history and comorbidities, signs and symptoms, 
current medical needs, and risk of an adverse event. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from July 24, 2023, through July 29, 2023.  
 
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 Group 3 power wheelchair (PWC) with single power 
options and expandable controller, harness, and electronics. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 3 PWC is covered when specific criteria 
are met. 
 
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 criteria for coverage are not met. Our physician reviewer found the enrollee had a stroke and has declined 
in function. She is able to walk 15 feet and has intact skin. She does not have high risk for skin breakdown, use 
a catheter intermittently, or spasticity. She does not require alternative means of managing the power drive. The 
records do not show that the criteria are met and that the requested Group 3 PWC with upgraded electronics is 
medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 3 power wheelchair (PWC) with single power options and expandable controller, 
harness, and electronics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness, electronic connection 
device, and controller shroud. 
 
You asked the Plan to pre-approve expandable controller components. You say that this is the appropriate 
equipment. The Plan denied your request. The Plan says the enrollee is able to operate the switches included 
with the power options themselves. 
 
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 expandable controller components. 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 adequate strength to manage the wheelchair's standard 
power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of expandable controller components have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an expandable controller, harness, electronic connection device, and 
controller shroud.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve routine transportation. You say that you want additional trips. The Plan 
denied your request. The Plan says additional routine transportation beyond 20 one-way trips per year is not 
covered.  

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 20 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional fractions of intensity-modulated radiation 
therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that the enrollee's treatment should not be delayed. The 
Plan denied your request. The Plan says the 8 additional fractions of IMRT are 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 IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case.  Our physician reviewer found the delivery of more than 20 fractions of radiation in the metastatic setting would 
be outside of the standard of care based on National Comprehensive Cancer Network (NCC) guidelines. The 
records do not show the need for going outside of the standard 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 IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve 8 additional fractions of intensity-modulated radiation therapy (IMRT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 22, 
2023. 
 
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 your benefit for the requested item or service 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 item or service was exhausted on date of service May 2, 2023, and July 
27, 2023. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) 
provided on August 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a removable unilateral partial denture (D5286) provided on 
June 29, 2023. 
 
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 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 a 
removable unilateral partial denture (D5286) provided on June 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the intraoral-
comprehensive series of radiographic images (D0210) provided on July 18, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 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 services provided was exhausted on date of service July 14, 2021.   
 
 
 
Specifically, the Plans contract states that a comprehensive oral evaluation is covered once every three 
calendar years. You previously received this service on July 14, 2021, less than three years prior, which was 
paid for by the Plan. Additionally, the Plans contract states that an intraoral comprehensive series of 
radiographic images is covered once every five calendar years. You previously received this service on July 14, 
2021, less than five years prior, which was paid for by the Plan. Therefore, you have exhausted the allowable 
benefit for these services. Therefore, we decided that the Plan does not have to pay for the comprehensive oral 
evaluation (D0150) and the intraoral-comprehensive series of radiographic images (D0210) provided on  
July 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the dental cleaning and the periodic oral 
evaluation provided on January 12, 2023. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services 
provided in this case are not payable as the claim was submitted untimely.  
 
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.  
 
  
 
 
 
 
We looked at this case file and the Plans rules. Based on this information, we decided that the Plan's rules for 
coverage of these services have not been met. Specifically, the Plans contract states that members will need to 
submit a reimbursement claim for dental services within 120 days of your purchase. However, the claim in this 
case was not submitted until August 24, 2023, which was untimely. Therefore, we decided that the Plan does 
not have to issue reimbursement for the dental cleaning and the periodic oral evaluation provided on  
January 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel provided June 7, 2023, billed with 
codes 87481-90-XU, 87798-90-XU x12, 87801-90 x3. 
 
You asked the Plan to pay for the laboratory service. You say that kindly review the attached documents and 
process this claim towards possible payment. The Plan denied your request. The Plan says panel testing should 
be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. Also, the standard of care for the evaluation of urinary incontinence is urinalysis with urine culture 
and sensitivity. Based on this information, we decided that Medicare rules for coverage of the laboratory 
service have not been met. Therefore, we decided that the Plan does not have to pay for the Urine PCR panel 
provided June 7, 2023, billed with codes 87481-90-XU, 87798-90-XU x12, 87801-90 x3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames and the progressive lens provided on May 18, 
2023. 
 
You asked the Plan to pay for the progressive lens. You say that you were expecting to get at least $150 
reimbursement. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 one standard pair of eyeglass lenses. 
 
We looked at the file and the Plan's rules. Specifically, the progressive lens is not considered standard lenses 
Based on this information, we decided that the Plan's rules for coverage of the progressive lens have not been 
met. Therefore, we decided that the Plan does not have to pay for the frames and the progressive lens provided 
on May 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Infuse BMP allograft and bone marrow aspirate for L1-
S1 posterior spinal decompression/instrumentation fusion surgery. 
 
You asked the Plan to pre-approve allograft and bone marrow aspirate. You say that the enrollee has failed 
several conservative treatments. The Plan denied your request. The Plan says the clinical value and 
effectiveness in the setting of posterior lumbar spine fusion surgery have not been demonstrated. 
 
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 allograft and bone marrow aspirate. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature 
that shows this to be an effective and/or safe treatment for the noted pathology. Further studies are needed to 
demonstrate this request has beneficial outcomes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of allograft and bone marrow aspirate have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Infuse BMP allograft and bone marrow aspirate for L1-S1 posterior 
spinal decompression/instrumentation fusion surgery.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional home health occupational therapy visits.  

You asked the Plan to pre-approve 6 additional home health services. You say that the enrollee had an injury to 
the spinal cord, and it is going to take approximately 2 years for them to fully recover. 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 the 
documentation does not support that the enrollee requires additional skilled rehabilitation services to provide 
treatment that is medically necessary. The enrollee does not require additional skilled rehabilitation services to 
effectively provide treatment, care, and/or services to improve their condition, perform a maintenance program 
to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been medically stable 
without any recent exacerbation of chronic medical problems or hospitalizations. The requested home health 
services are not medically 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 additional home health occupational therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81225, 81226, 81227, 81240, 81241, and 
81328 for date of service March 20, 2023. You asked the Plan to pay for procedure codes 81225, 81226, 81227, 81240, 81241, and 81328. 

You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 81225, 81226, 81227, 81240, 81241, and 81328 for date of 
service March 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness, electronic connection 
device, extra 4-inch link for a head support, and phone holder for a power wheelchair. 
 
You asked the Plan to pre-approve power wheelchair components. You say that this is medically necessary to 
facilitate the enrollee's primary medical purposes. The Plan denied your request. The Plan says there is no 
medical need for these components. 
 
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 power wheelchair components. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is able to manage the wheelchair's standard power drives. The 
phone holder is a convenience feature and the extra 4-inch link is included in the head rest hardware itself so 
should not be unbundled from that component. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair components have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an expandable controller, harness, electronic connection device, extra 4-
inch link for a head support, and phone holder for a power wheelchair.