Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete lower denture (D5120) provided on April 10, 
2023. 
 
You asked the Plan to pay for the dental service. You say that your previous denture did not fit correctly and 
you could not use them without being in pain. 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 the Plan paid for a complete lower denture (D5120) on November 16, 2022; therefore, your benefit for 
the requested item or service was exhausted on the date of service of November 16, 2022. Therefore, we 
decided that the Plan does not have to pay for a complete lower denture (D5120) provided on April 10, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and services received on April 20, 2022. 
 
You asked the Plan to pay for the office visit and services. You say that the services should be covered. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
 The enrollee ended Medicare Hospice benefits on April 11, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the office visit and 
services received on April 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair (E2611, E0971, E2601). 
 
You asked the Plan to pre-approve the manual wheelchair. You say that the additional wheelchair is medically 
necessary. The Plan denied your request. The Plan says extra or duplicate equipment is not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a power wheelchair. a power wheelchair serves the same purpose as the 
manual wheelchair. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair 
(E2611, E0971, E2601).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thorax. 
 
You asked the Plan to pre-approve the CT scan. You say that the enrollee has a papillary thyroid cancer 
diagnosis, and the imaging is needed to determine if there is a recurrence. The Plan denied your request. The 
Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee certainly has clinical indication 
for a CT of the chest, but an approval has already been done according to the plan within the past 60 days, but 
no result is in the records submitted. The plan indicates a CT of the chest was done on June 5, 2023, but no 
report is in the submitted records. 
 
 
  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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the thorax.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 28, 2023. 
 You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided on February 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Ottobock C leg microprocessor knee (L5856). 
 
You asked the Plan to pre-approve an Ottobock C leg microprocessor knee. 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 follows Medicare rules. Medicare rules say that lower limb prostheses are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Ottobock C leg microprocessor 
knee. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
requested Ottobock C leg microprocessor knee is not medically necessary. The documentation indicates that 
the requested item has features that exceed the enrollee's medical need and also the documentation is 
conflicting that the enrollee requires the C-leg. The enrollee's activities appear to be able to be met through a 
mechanical knee and there are no extenuating factors on the medical progress notes that require a heavier 
microprocessor knee. Furthermore, the documentation does not support the K3 level of ambulation given the 
enrollee's functional activities, comorbidities, and his primary goal of household and community ambulation 
with the use of a walker. 
 
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 Ottobock C leg microprocessor knee have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an Ottobock C leg microprocessor knee (L5856).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from December 
17, 2022, to December 31, 2022. 
 You asked the Plan to pay for SNF care. You say that the services were medically necessary. The Plan denied 
your request. The Plan says there were no skilled services needed. 
 
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 pay for 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 based on the documentation provided, the enrollee no longer qualified for SNF 
coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented 
skilled therapy needs. Daily skilled services are not shown to have been required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. 
 
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 pay for skilled nursing facility (SNF) care provided from December 17, 2022, to December 31, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a lower limb prosthesis with a replacement socket and suspension 
with all standard additions (L5321, L5624, L5649, L5650, L5651, L5652, L5679, L5920, L5950) and K3-level 
components, including microprocessor knee (L5828, L5845, L5848, L5856), flex-walk style foot with axial 
rotation unit (L5981, L5986), as well as prosthetic socks/shrinkers (L8430, L8460, L8480). 
 
You asked the Plan to pre-approve a lower limb prosthesis and all additions. You say that you need a new 
prosthetic leg. The Plan denied your request. The Plan says that the requested K3 prostheses exceeds the 
enrollee's needs. 
 
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 a lower limb prosthesis and all 
additions. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found that you rely on your prosthesis to live independently at  
home and to go out in the community. Based on the documentation provided you clearly have K3 potential. 
Lesser components would amount to sub-standard care and would not meet your needs. 
 
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 lower limb prosthesis and all additions have been met. Therefore, we decided 
that the Plan has to pre-approve a lower limb prosthesis with a replacement socket and suspension with all 
standard additions (L5321, L5624, L5649, L5650, L5651, L5652, L5679, L5920, L5950) and K3-level 
components, including microprocessor knee (L5828, L5845, L5848, L5856), flex-walk style foot with axial 
rotation unit (L5981, L5986), as well as prosthetic socks/shrinkers (L8430, L8460, L8480).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on March 23, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a nursing facility visit 
provided on March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation (RFA) (64624). 
 
You asked the Plan to pre-approve genicular RFA. 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 genicular RFA. 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 an experimental/ investigational procedure at this time. It is the subject of 
ongoing clinical trials. Therefore, the request is deemed 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 genicular RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular radiofrequency ablation (RFA) (64624).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental consultation. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is not payable as the provider is not enrolled in 
the Medicare program.  
 
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. 
 
A 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 pre-approve a dental consultation.
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 the enrollee will benefit and improve 
with the services provided in a LTACH. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient acute care and does not require transfer to a LTACH.  
 
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 the enrollee appears to be improving and should only require short-term additional 
acute care services that can safely be provided at the current facility until more appropriate and stable for 
transfer to a lower level of care soon. The enrollee does not require services at the LTACH that are not already 
available at the current 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 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3rd and 4th additional level bilateral radiofrequency 
ablation (RFA) (64636). 
 
You asked the Plan to pre-approve 3rd and 4th additional level bilateral RFA. 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 follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and 
necessary for patients who meet certain criteria. 
 
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 3rd and 4th additional level bilateral 
RFA. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
utilization limit as per the LCD is 2 levels at one session. There are no extraordinary circumstances identified 
in the notes. Therefore, the request for additional levels is deemed 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 3rd and 4th additional level bilateral RFA have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 3rd and 4th additional level bilateral radiofrequency 
ablation (RFA) (64636).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on January 27, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that you are 
high risk for a breast condition and feel the MRI should be considered a routine exam and not diagnostic. 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 $195 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $195 copayment for a magnetic resonance imaging (MRI). This item/service 
falls within the outpatient diagnostic tests 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 a magnetic resonance imaging (MRI) provided on January 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bifocal lenses (V2203), a miscellaneous vision item (V2799), 
polycarbonate lenses (V2784) and anti-reflective coating (V2750) provided on February 7, 2023. 
 
You asked the Plan to pay for bifocal lenses (V2203), a miscellaneous vision item (V2799), polycarbonate 
lenses (V2784) and anti-reflective coating (V2750). You say that the Plans policy clearly states that they will 
pay up to $200 per year for glasses. You also say the Plan is denying any payment. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
 
  We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 2, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for bifocal lenses (V2203), a miscellaneous 
vision item (V2799), polycarbonate lenses (V2784) and anti-reflective coating (V2750) have not been met. 
Therefore, we decided that the Plan does not have to pay for bifocal lenses (V2203), a miscellaneous vision 
item (V2799), polycarbonate lenses (V2784) and anti-reflective coating (V2750) provided on February 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (A4239). 
 
You asked the Plan to pre-approve the CGM. 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 you do not meet the 
clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes, 
use insulin or have a history of problematic hypoglycemia, had an in-person visit with their treating physician 
to evaluate their diabetes control and to determine whether the criteria for coverage have been met.  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) (A4239).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wheelchair management training provided 
on March 29, 2023. 
 
You asked the Plan to waive the copayment for wheelchair management training. You say that you did not 
receive any physical therapy, training, or management services. 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 $40 
copayment for in-network outpatient rehabilitation services provided in an outpatient hospital. 
 
You have been asked to pay a $40 copayment for wheelchair management training. This item/service falls within the in-network outpatient rehabilitation services provided in an outpatient hospital 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 wheelchair management training provided on March 29, 
2023.