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

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the home ventilator. You say that the enrollee has a complex medical 
history including advanced COPD with respiratory failure and impaired lung capacity. You also say that the 
enrollee did qualify for non-invasive ventilation (NIV) apparatus in Form of Life 2000.  The Plan denied your 
request.  The Plan says under Medicare guidelines, your request is not medically necessary as the records show that the 
ordered settings for the noninvasive ventilator show it is going to be used only in a bi-level pressure mode as a 
respiratory assist device (RAD). 
 
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 the  home ventilator. Our reviewer says 
that this item is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has chronic respiratory failure from chronic obstructive pulmonary disease. The record indicates that the 
enrollee was previously treated with a positive airway pressure (PAP) device. The provided primary source 
documentation does not contain sufficient information in the medical record to justify the treatment selected. 
The enrollee could be treated with a BiPAP machine with AVAPS capability and failure of such a device has 
not been documented. 
 
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  home ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation - established patient 
(D0120), bitewings - four radiographic images (D0274), and prophylaxis - adult (D1110) provided on April 27, 
2023. 
 
You asked the Plan to pay more for the dental services. You say that you had routine dental services at your 
dentist where you have been a patient for15 years. You also say that you believe the plans reimbursement 
should be at least 67% of the provider billed amount and any adjustment to this claim amount should be 
returned to you directly. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from 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.  
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the periodic oral evaluation - established 
patient (D0120), bitewings - four radiographic images (D0274), and prophylaxis - adult (D1110) provided on 
April 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for interim complete maxillary denture (D5810), interim 
complete mandibular denture (D5811), and an alveoloplasty in conjunction with extractions (D7310) provided 
on July 11, 2023, to July 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are nowhere near your limit. You also say 
you did not receive this procedure of a reshape bone of the lower left quadrant (D7310). 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 July 11, 2023. 
Specifically, the record shows that you reached your $3,000 maximum during the visit on July 11, 2023. 
Therefore, we decided that the Plan does not have to pay for interim complete maxillary denture (D5810), 
interim complete mandibular denture (D5811), and an alveoloplasty in conjunction with extractions (D7310) 
provided on July 11, 2023, to July 12, 2023.  
 
Your complaint about potentially being charged for services not received is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Sprint peripheral nerve stimulator (PNS) (64555). 
 
You asked the Plan to pre-approve the Sprint PNS. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested device is not reasonable and 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 Sprint PNS. 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 experimental therapy. It is the subject of ongoing clinical trials. 
 
   
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 Sprint PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Sprint peripheral nerve stimulator (PNS) (64555).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-adjunctive, non-implanted continuous glucose 
monitor (CGM) or receiver (E2103) and supply allowance for non-adjunctive, non-implanted CGM (A4239). 
 
You asked the Plan to pre-approve a non-adjunctive, non-implanted CGM or receiver and supply allowance. 
You say that the patient has a history of Hypoglycemia Systematic hypoglycemic episodes and is a high fall 
risk. You also say that you are trying to prevent any further falls. The Plan denied your request. The Plan says 
under Medicare guidelines, this request is not medically necessary. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a non-adjunctive, non-implanted CGM 
or receiver and supply allowance. Our reviewer says that the criteria for coverage have not been met. Our 
physician reviewer found the coverage criteria for a CGM requires insulin use or low blood glucoses (BGs) 
below 54 with symptoms. Our reviewer also found that we are not given any data to support BG levels in this 
range and the patient is on medications that do not typically cause low BGs. 
 
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 non-adjunctive, non-implanted CGM or receiver and supply allowance have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a non-adjunctive, non-
implanted continuous glucose monitor (CGM) or receiver (E2103) and supply allowance for non-adjunctive, 
non-implanted CGM (A4239).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the enrollee would benefit from a CGM. The Plan 
denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the records indicates that the enrollee 
has diabetes. The record provided does not indicate that the enrollee is being treated with insulin or has 
problematic hypoglycemia as defined by the Medicare rules. The elements of the coverage criteria are not 
satisfied. The requested service is not recommended. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided on March 14, 2023. 
 
You asked the Plan to pay for a crown. You say that this should be covered. The Plan denied your request. The 
Plan says this is not a covered service. 
 
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 crown 
(D2740) provided on March 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dayspring Active Compression System (K1024) and 
garment (K1033). 
 
You asked the Plan to pre-approve the Dayspring Active Compression System and garment. You say that it is 
medically necessary for ongoing at home management of lymphedema. You also say that other therapies were 
deemed insufficient to address the enrollee's chronic and progressive symptoms. The Plan denied your request. 
The Plan says a review of the current medical literature does not support this service to be reasonable and 
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 Dayspring Active Compression 
System and garment . Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case.  
 Our physician reviewer found this specific device is medically reasonable but not necessary, as there is 
insufficient data to support its use over other pneumatic devices. 
 
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 Dayspring Active Compression System and garment  have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Dayspring Active Compression System 
(K1024) and garment (K1033).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 10, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams 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 June 10, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the brain. 
 
You asked the Plan to pre-approve the MRI. You say that the services are medically necessary to stage the 
enrollee's multiple sclerosis to see if it has progressed. The Plan denied your request. The Plan says that they 
did not receive information showing why the testing was medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
MRI is medically necessary. Our physician reviewer found the enrollee has multiple sclerosis (MS). It would 
be reasonable and necessary to obtain a baseline study to evaluate for disease progression and to set a baseline 
prior to initiation of a disease-modifying therapy (DMT). In as much this request can be said to be appropriate. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
a magnetic resonance imaging (MRI) of the brain.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you just had a stroke and are at risk of not being 
able to regain your function if sent home. The Plan denied your request. The Plan says you can receive the care 
needed in another level of care such as home with home health, or outpatient therapy in residential care. 
 
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 you do have daily skilled nursing needs that require the specialized skill, knowledge, 
and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled 
nursing and skilled therapy on an inpatient basis in a skilled nursing facility (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 skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a single-photon emission computerized tomography 
(SPECT) scan (78803). 
 
You asked the Plan to pre-approve a SPECT scan. You say that the requested procedure is Food and Drug 
administration approved for the diagnosis of Lewy Body Dementia. You also say that it is one of the indicative 
biomarkers in the Fourth Consensus Criteria for the Clinical Diagnosis of Dementia with Lewy Bodies for 
those patients that do not fulfill clinical criteria exclusively on clinical features. The Plan denied your request. 
The Plan says this request does not meet the Medicare or health plan coverage criteria. 
 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 SPECT scan. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested study is not being performed for an indication for which Medicare covers this 
procedure. At this time the diagnosis of Lewy body dementia (LBD)/dementia with Lewy bodies (DLB) is 
primarily made on a clinical basis. Our reviewer also found that performance of advanced imaging is not 
readily indicated for use. Therefore, this request would not be reasonable and 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 SPECT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a single-photon emission computerized tomography (SPECT) scan (78803).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve integrated biopsychosocial assessment (90791) 60- 
minute individual psychotherapy (90837) 30-minute individual psychotherapy (90832) 45-minute individual 
psychotherapy (90834). 
 
You asked the Plan to pre-approve the mental health visits. You say that the medical records provided will 
show proof of medical necessity. The Plan denied your request. The Plan says 3 visits with a mental health 
provider was approved in May 2023. There is no supporting documentation that the enrollee requires additional 
visits.  
 
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 mental health visits. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee suffered from unspecified dementia with behavioral disturbance and 
depression with anxiety. Based on review the records provided, the enrollee was not showing any symptoms of 
illness including depression and anxiety but has been stable. The enrollee was given 3 visits for psychotherapy. 
The enrollee has been active in activities including community outings and family and friend involvement. 
Based on review the records provided this enrollee is not showing the symptoms of illness which would require 
the enrollee to be seen for individual psychotherapy. The psychotherapy performed was not found to be 
reasonable or 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 the mental health visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve integrated biopsychosocial assessment (90791) 60- minute individual 
psychotherapy (90837) 30-minute individual psychotherapy (90832) 45-minute individual psychotherapy 
(90834).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from April 12, 2023, through 
April 19, 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 with metastatic disease as well as other complex conditions was admitted for acute on 
chronic kidney injury. Reportedly, the enrollee was unable to receive one of her treatments due to an abnormal 
kidney function. The enrollee met the criteria for an inpatient level of care. At minimum, the enrollee had acute 
on chronic kidney disease as well as concerns for a urinary tract infection with failure of outpatient treatment. 
A urine culture was sent and sometimes can take just over two midnights to result. Additionally, the enrollee 
has a complex medical history that further complicates her problem of an acute kidney injury.  
 
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 April 12, 2023, through April 19, 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.