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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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. 
 
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 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. If this enrollee has severe chronic obstructive pulmonary disease (COPD) and chronic carbon 
dioxide (CO2) retention, they may benefit from bilevel positive airway pressure (BiPAP) with average volume-
assured pressure support (AVAPS) during sleep. Medicare does not cover a home ventilator when used at 
settings that can be provided with BiPAP. In addition, a ventilator may be contraindicated in the presence of 
systolic heart failure. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the magnetic resonance imaging (MRI) shows foraminal stenosis and facet 
degenerative joint disease (djd). The cause of the back pain is unclear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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. 
 
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 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. There is no arterial blood gas (ABG) done while stable to document chronic carbon dioxide (CO2) 
retention. If that is present, you may benefit from bilevel positive airway pressure (BiPAP) with average 
volume-assured pressure support (AVAPS) during sleep as an outpatient. Medicare does not cover a home 
ventilator when used at settings that can be provided with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical procedure for isolation of tooth with rubber 
dam tooth #7 (D3910), and canal preparation and fitting of preformed dowel or post tooth #7 (D3950). 
 
You asked the Plan to pre-approve the surgical procedure and canal preparation and fitting of preformed dowel 
or post. You say that these procedures are medically necessary and the doctor needs the authorization for 
treatment. The Plan denied your request. The Plan says D3910 rubber dam for tooth 7 and D3950 fitting and 
placing a post in a tooth for tooth 7 are not listed as 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 a 
surgical procedure for isolation of tooth with rubber dam tooth #7 (D3910), and canal preparation and fitting of 
preformed dowel or post tooth #7 (D3950).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fulphila. 
 
You asked the Plan to pre-approve Fulphila. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Fulphila. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the requested drug is not FDA-approved 
for the enrollees diagnosis. The use is not supported by one of the major drug compendia or by clinical 
research that appears in a CMS-approved medical journal.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fulphila have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Fulphila.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 Zilretta. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no evidence of superior efficacy of 
Zilretta over triamcinolone. The request is not 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for SNF 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 daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only in a skilled nursing 
facility. 
 
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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36005 billed for date of service October 26, 
2022. You asked the Plan to pay for procedure code 36005. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 36005 is bundled into payment for 
code 75860. 
 
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 36005 is a column II code to column I code 75860. The code at issue 
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 
36005 billed for date of service October 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor kit. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 sensor kit. The Plan denied your request. The Plan 
says the enrollee does not require insulin three or more times daily. 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does use insulin with at 
least three daily injections. Based on this information, we decided that Medicare rules for coverage of the 
Freestyle Libre 2 sensor kit have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2 sensor kit.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93000 billed for date of service September 
21, 2022. 
 You asked the Plan to pay for procedure code 93000. You say that the services are medically necessary. The 
Plan denied your request. The Plan says payment for code 93000 is bundled into payment for code 93228. 
 
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 93000 
is a column II code to column I code 93228. 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 93000 billed for date of service September 21, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional speech therapy visits. 
 
You asked the Plan to pre-approve speech therapy visits. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says 12 additional speech 
therapy visits are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 speech therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that the enrollee has previously been treated with outpatient 
therapies and should be independent with a home exercise program. The enrollee has no recent injury or a 
decline in function. The additional therapy services are not appropriate duration and frequency for treatment of 
the enrollees medical condition and therefore 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 speech therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 12 additional speech therapy visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an OON provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you want to see an out-of-network provider. 
The Plan denied your request. The Plan says the service can be provided by an in-network provider. 
 
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 
physical therapy to be provided by an OON provider.
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 at a high risk to return to a 
short-term acute care hospital if they are discharged to a skilled nursing facility. You say that the enrollee needs 
LTACH level of care. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary, and the enrollee can safely receive the care they need in the current hospital setting. 
 
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 enrollee is still unstable and requires short-term additional acute care hospital 
services that can be safely provided at the current facility until they are more stable and ready for 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 LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ground mileage (A0425) and air transport (A0434) 
provided on May 5, 2020. 
 
You asked the Plan to pay for the ground mileage and air transport. You say that you sent this within 90 days of 
the date of service which is the timely filing guideline per your contract. You also say that you would like this 
claim to be reprocessed and paid. The Plan denied your request. The Plan says this claim is untimely and does 
not meet the exception criteria guidelines. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 The record shows that a claim for the ground mileage and air transport was not filed until October 20, 2022. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and air transport 
(A0434) provided on May 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported porcelain/ ceramic crown (D6058). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you have been approved for D6057 already which means 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. Therefore, we decided that the Plan does 
not have to pre-approve abutment supported porcelain/ ceramic crown (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on November 8, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that the service in question was for your annual 
routine vision exam. You also say that according to your plan documents, this is covered, but you would pay 
$10 for in-network or $40 for out-of-network. The Plan denied your request. The Plan says since the claim was 
billed with medical diagnosis codes the eye refraction was denied correctly. 
 
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 performed during a routine vision exam. 
 
 
 
 We looked at the file and the Plan's rules. The record shows that you did not receive a routine vision exam, but 
instead received a Medicare covered eye exam for several diagnoses. Based on this information, we decided 
that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan 
does not have to pay for the eye refraction (92015) provided on November 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal aortic aneurysm (AAA) screening (76706) 
provided on August 31, 2022. 
 You asked the Plan to pay for the AAA screening. You say that you feel this service should be covered because 
the provider is requesting this service to be done every 6 to 12 months to constantly monitor progress. The Plan 
denied your request. The Plan says this benefit has been exhausted. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Though the Plan does not cover screening tests aside from the listed exceptions, the Plan offers coverage for a 
one-time abdominal aortic aneurysm (AAA) screening for people at risk. The record shows that you received 
an AAA screening on October 21, 2020, and your AAA screening benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the abdominal aortic aneurysm (AAA) screening (76706) 
provided on August 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92014), eye refraction (92015), and contact 
lens fitting (92310) provided on November 22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam, refraction, and contact lens fitting. You say that you went to this 
provider's office due to pain in your left eye, and they found that you have cataracts. You also say that you had 
to pay for the eye exam and contacts out of pocket due to many offices not accepting your plan. The Plan 
denied your request. The Plan says these services were rendered by a provider who is not contracted in the 
Plan's network. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the eye exam (92014), eye refraction (92015), and 
contact lens fitting (92310) provided on November 22, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental crowns (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 September 20, 2022. 
Therefore, we decided that the Plan does not have to pre-approve dental crowns (D2740).