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

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested device is not medically necessary. 
 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 ventilator. Our reviewer says that the 
documentation does not support that the requested ventilator is medically reasonable or necessary. Our 
physician reviewer found you have diagnoses of chronic respiratory failure consequent to chronic obstructive 
pulmonary disease, obesity hypoventilation and obstructive sleep apnea. The provided records document that 
the home ventilator is being requested for use in intelligent volume assured pressure support (IVAPS) mode 
which is a modality that could be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS 
and a back-up rate. The provided records do not document trial and failure of a BiPAP device with AVAPS and 
a back-up rate. Therefore, you do not meet criteria for the requested device. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 You asked the Plan to pre-approve Keytruda. You say that that the enrollee has stage 4 cancer, and this 
treatment is to help them. The Plan denied your request. The Plan says that the step therapy requirements have 
not been met.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Keytruda. Our reviewer says that 
Keytruda is not medically necessary. Our physician reviewer found that the Plan requires docetaxel or 
paclitaxel as first line before abraxane. Also, there is no indication on why the enrollee cannot have either of 
the Plan's required drugs. Therefore, the service is not 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an abdomen and pelvis computed 
tomography (CT) scan provided on February 01, 2023. 
 
You asked the Plan to waive the copayment for an abdomen and pelvis computed tomography (CT) scan. You 
say that you do not agree with the copayment. 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 $175 
copayment for all other diagnostic and nuclear medicine radiological services. 
 
You have been asked to pay a $175 copayment for an abdomen and pelvis computed tomography (CT) scan. 
This item/service falls within the all other diagnostic and nuclear medicine radiological services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an abdomen and pelvis computed tomography 
(CT) scan provided on February 01, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cordless waterpic (D0001) provided on March 3, 2023. 
 
You asked the Plan to pay for the dental service. You say that you would like the Plan to cover the cordless 
waterpic. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
the cordless waterpic is not covered by the Plan. 
 
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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cordless 
waterpic (D0001) provided on March 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract surgery. 
 
You asked the Plan to pre-approve cataract surgery. You say that the cataract surgery was denied because the 
requisite clinicals were not provided. You also say that they now have been provided. The Plan denied your 
request. The Plan says this is not medically necessary and reasonable. 
 
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 cataract surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the available records show an examination from 2021, at which time the enrollee's visual acuity 
was 20/25 in both eyes. Our physician reviewer also found that there are no recent progress notes to 
demonstrate a visually significant cataract affecting activities of daily living.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cataract surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve cataract surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87500, 87640, 87652, and 87798 for 
date of service April 14, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87500, 87640, 87652, and 87798. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as 
billed. 
 
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 find that CPT codes 87481, 87500, 87640, 87652, and 87798 are not payable as billed. Specifically, there is 
a more appropriate lab panel that should be billed when one or more CPT codes are included in the same panel. 
Based on this information, we decided that Medicare rules for coverage of procedure codes 87481, 87500, 
87640, 87652, and 87798 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 87481, 87500, 87640, 87652, and 87798 for date of service April 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 12, 2023, billed with 
codes 87481, 87641, 87798, 87640, 87500, 87651, 87471, 87493, 87529, 87563, 87653, and 87561. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 12, 2023, billed with codes 87481, 87641, 87798, 87640, 87500, 87651, 87471, 87493, 87529, 87563, 
87653, and 87561.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that you would like to request reconsideration of 
the denied claim and that the services requested are medically necessary. The Plan denied your request. The 
Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the calf pads and cup holder.  
 
You asked the Plan to pre-approve the calf pads and cup holder. You say that the items should be covered. The 
Plan denied your request. The Plan says these items are not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the calf pads and cup holder.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. You say that the enrollee has tried conservative treatment and 
would benefit from lumbar epidural steroid injections to relieve their pain. The Plan denied your request. The 
Plan says an epidural steroid 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 an 
epidural steroid injection i snot medically necessary. Our physician reviewer found that there is no 
documentation of lumbar radiculopathy, radicular pain, or neurogenic claudication due to disc herniation, 
osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal or central spinal 
stenosis, or post-laminectomy syndrome. Therefore, the enrollee does not meet the LCD coverage criteria. 
 
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 an epidural steroid injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need this level of care. The Plan 
denied your request. The Plan says LTACH services are not medically necessary, reasonable, or appropriate for 
your diagnosis and condition at this time. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you do not require services that are not already available at the current facility. 
Services can safely be provided at the current facility until you are more stable for transfer to 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Botox. 
 
You asked the Plan to pre-approve Botox. You say that your condition has worsened. The Plan denied your 
request. The Plan says Botox is not supported for your condition. 
 
The Plan follows Medicare rules. Medicare rules state that botulinum toxins may be covered for certain 
indications. 
 
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 Botox. Our reviewer says that you do 
not meet criteria for use of Botox. Our physician reviewer found the record indicates that you have Raynaud's syndrome with gangrene. This condition is not one for which coverage is available under Medicare rules. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Botox.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the mental health office visit to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the mental health office visit. You say that it was hard finding a provider 
who is in-network with the Plan. The Plan denied your request. The Plan says there are network providers that 
can provide these services. 
 
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 records show that the provider 
is also not licensed to practice in Massachusetts. 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 mental health office visit 
to be provided by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation miles. 
 
You asked the Plan to pre-approve the additional miles. You say that you need the additional miles to see a 
specialist. The Plan denied your request. The Plan says the benefit limit for your non-emergency transportation 
trips is limited to 75 miles each way. 
 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 Plans coverage rules apply in this 
case. The Plan covers a maximum of 75 miles one-way per trip.  
 
We looked at your request, the records in the case file, and the rules. You are requesting a trip of 220 miles. 
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 miles.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is critically ill and is 
requiring LTACH level of care.  The Plan denied your request. The Plan says an LTACH admission is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the documentation does not support that LTACH services are medically 
appropriate. The enrollee is receiving the appropriate care in the current acute care setting as provided by the 
Health Plan.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion (CPM) device to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a CPM device. You say that the item is medically necessary. The Plan 
denied your request. The Plan says there are in-network providers who can supply this device. 
 
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 
a continuous passive motion (CPM) device to be provided by an out-of-network (OON) provider.
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. You say that the enrollee has already failed bi-
level therapy and while other devices can provide a similar mode called AVAPS, they are not equipped with 
the same pressure and flow ranges or features necessary for the enrollee's needs for advanced ventilation. 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 
has class 3 obesity, obesity hypoventilation syndrome, and chronic pain on chronic narcotics. However, 
Medicare does not cover a home ventilator for the treatment of obesity hypoventilation syndrome, or when 
used at settings that can be provided with a BiPAP. Therefore, the denial is upheld. 
 
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 unspecified diagnostic procedure (D0999), core buildup 
(D2950), gingivectomy or gingivoplasty (D4212) for teeth 2 and 8, occlusal guard (D9944), localized delivery 
of antimicrobial agents into diseased crevicular tissue (D4381) for teeth 2, 3, 14, 15, 23, and 24, and gingival 
irrigation (D4921). 
 
  You asked the Plan to pre-approve unspecified diagnostic procedure (D0999), core buildup (D2950), 
gingivectomy or gingivoplasty (D4212) for teeth 2 and 8, occlusal guard (D9944), localized delivery of 
antimicrobial agents into diseased crevicular tissue (D4381) for teeth 2, 3, 14, 15, 23, and 24, and gingival 
irrigation (D4921). You say that you feel this should be approved, because it is medically necessary to have 
this done. The Plan denied your request. The Plan says these services are non-covered services 
 
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 pre-approve 
unspecified diagnostic procedure (D0999), core buildup (D2950), gingivectomy or gingivoplasty (D4212) for 
teeth 2 and 8, occlusal guard (D9944), localized delivery of antimicrobial agents into diseased crevicular tissue 
(D4381) for teeth 2, 3, 14, 15, 23, and 24, and gingival irrigation (D4921).