Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve lumbar fusion surgery at an inpatient level of care. 
 
You asked the Plan to pre-approve lumbar fusion surgery at an inpatient level of care. You say that this is 
medically necessary. The Plan denied your request. The Plan says that medical necessity for inpatient level of 
care is not met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 lumbar fusion surgery at an inpatient 
level of care. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee is having an extensive 3 level lumbar fusion 
surgery with interbody grafts and screws. There is high blood loss and increased pain with long operative time 
for this surgery. A 3-day inpatient stay is reasonable and within the care standard for this extensive multilevel 
fusion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar fusion surgery at an inpatient level of care have been met. Therefore, we 
decided that the Plan has to pre-approve lumbar fusion surgery at an inpatient level of care.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) provided on May 23, 
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 December 6, 2021. 
Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120) provided on 
May 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an extraction (D7210) provided on May 2, 2023. 
 
You asked the Plan to pay more 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 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 an extraction (D7210) provided on May 2, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home ventilator provided on April 23, 2023. 
 
You asked the Plan to pay for the home ventilator. You say that the requested ventilator is medically necessary 
for the enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary for 
this enrollee 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 pay for the home ventilator, any type. Our reviewer 
says that the item is not medically necessary. Our physician reviewer found that the record indicates the 
enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The record also indicates 
that the enrollee was successfully treated with a BiPAP device. The provided primary source documentation 
does not contain sufficient detailed 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. The elements of the coverage criteria are not satisfied; therefore, requested item cannot be 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pay for the home ventilator provided on April 23, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says that an epidural 
steroid injection is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 injection. Our reviewer says that the 
enrollee does meet the LCD coverage criteria. Our physician reviewer found that the enrollee has chronic neck 
pain with radiation into both arms. The enrollee's magnetic resonance imaging (MRI) shows multi-level 
degenerative disc disease, multi-level foraminal stenosis and a disc protrusion at level C7-T1. Therefore, the 
request meets the LCD criteria and is medically 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 the injection have been met. Therefore, we decided that the Plan has to pre-
approve an epidural steroid injection.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110) provided on August 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says 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 January 11, 2022, and 
April 18, 2022. Therefore, we decided that the Plan does not have to pay for a cleaning (D1110) provided on 
August 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on 
October 26, 2022. 
 
You asked the Plan to reimburse you for the purchased portable oxygen concentrator. You say that you 
disagree with the denial of payment and would like the Plan to reconsider payment. The Plan denied your 
request. The Plan says you purchased the concentrator out right when it is supposed to be a rental item. 
Therefore, no payment will be made. 
 
The Plan must follow Medicare rules. Medicare rules say that that Part A/Part B Medicare Administrative 
Contractors may not pay for oxygen equipment that is purchased on or after June 1, 1989.  
 
  We looked at the file and Medicare rules. Specifically, the record shows you purchased the oxygen 
concentrator, and Medicare does not pay for purchased oxygen equipment. The Plan only pays for rented 
oxygen equipment. Based on this information, we decided that Medicare rules for coverage of portable oxygen 
concentrator have not been met. Therefore, we decided that the Plan does not have to reimburse you for the 
portable oxygen concentrator purchased on October 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi. 
 
You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says Imfinzi is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug. Our reviewer says that Imfinzi 
is not medically necessary.  Our physician reviewer found that the requested use of Imfinzi is not FDA-
approved. Imfinzi is also not supported by one of the major drug compendia or by clinical research. 
 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Imfinzi.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cogenex amniotic membrane (Q4229). 
 
You asked the Plan to pre-approve Cogenex amniotic membrane. You say that this is medically necessary. The 
Plan denied your request. The Plan says the clinical value and effectiveness of the Cogenex amniotic 
membrane skin graft substitute to speed up healing for a lesion associated with Mohs surgery has not been 
demonstrated in the peer-reviewed literature. 
 
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 Cogenex amniotic membrane. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the clinical value and effectiveness of the Cogenex amniotic membrane 
skin graft substitute has not been demonstrated in the peer-reviewed literature to speed up healing for a lesion 
associated with Mohs surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cogenex amniotic membrane have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Cogenex amniotic membrane (Q4229).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for each drug injection service provided from 
November 7, 2022, to November 21, 2022. 
 
You asked the Plan to waive the copayments for each drug injection service. You say that you were told by the 
Plan you would not have to pay this amount. 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 $295 
copayment for outpatient surgery and other services provided at an outpatient hospital.  
 
 Date of Service CPT Code Allowed Amount Copayment 
November 7, 2022 96365 $200.39 $200.39 
November 7, 2022 96366 $39.20 $39.20 
November 14, 2022 96365 $200.39 $200.39 
November 14, 2022 96366 $39.20 $39.20 
November 21, 2022 96365 $200.39 $200.39 
November 21, 2022 96366 $39.20 $39.20 
Total $718.77 
 
You have been asked to pay up to a $295 copayment for each drug injection service. This item/service falls 
within the outpatient surgery 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 copayments for each drug 
injection service provided from November 7, 2022, to November 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removable appliance therapy services (D8210) provided on 
December 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
removable appliance therapy services (D8210) provided on December 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint arthrodesis with instrumentation. 
 
You asked the Plan to pre-approve SI joint arthrodesis. You say that you are appealing the denial. The Plan 
denied your request. The Plan says that the surgery 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 SI joint arthrodesis. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that detailed documentation is not evident regarding imaging or radiographic 
evidence supporting a sacroiliitis pathology. There is no clear history of SI joint pain onset or failure of 
conservative treatment directed to the SI joint. Multiple other plausible pain generators  including at the 
lumbosacral spine  are evident. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint arthrodesis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve sacroiliac (SI) joint arthrodesis with instrumentation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliances (E0656, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the items are medically 
necessary. The Plan denied your request. The Plan says your records do not show that you tried the basic pump 
more than the one time, 20 minute trial session. Additionally, your records show that you have chronic venous 
insufficiency causing your leg swelling, a condition that Medicare says will not allow coverage for this E0652 
pump. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliances (E0656, E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an OON provider.  
 
You asked the Plan to pre-approve the office visit. You say that the service is medically necessary. The Plan 
denied your request. The Plan says this service is available with in-network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office visit to be provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment center stay from January 20, 2023, to February 
16, 2023. 
 
You asked the Plan to pay for the treatment center stay. You say that you are seeking reimbursement for the 
services and were unaware that the treatment center was not under contract with Medicare. The Plan denied 
your request. The Plan says the services were obtained from a provider who is not under contract with the Plan 
and not certified for Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the treatment center stay from January 
20, 2023, to February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve the injection. You say that you need relief from the injections for your lower 
back problems, which extends into your hips. The Plan denied your request. The Plan says a sacroiliac joint 
injection 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 injection. Our reviewer says that a 
sacroiliac joint injection is not medically necessary.  Our physician reviewer found that there is no 
documentation on physical examination of tenderness to the sacroiliac joint and no mention of sacroiliac 
provocative testing being completed with positive findings. Therefore, the requested sacroiliac joint injection is 
not medically reasonable or necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint injection.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says they are unable to determine medical necessity without medical 
records. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of home health services have been met. There are no medical records within the casefile. Without the requested clinical information, we are unable to 
determine if the requested services are medically necessary. Therefore, we decided that the Plan does not have 
to pre-approve home health services.