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

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on 
December 15, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the items at issue are not payable 
as they were not purchased through the Plans select hearing aid provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are covered 
only when purchased through the Plans select hearing aid provider. However, the hearing aids in this case 
were not purchased from the Plans select hearing aid vendor. Therefore, we decided that the Plan does not 
have to issue reimbursement for the hearing aids (V5261) purchased on December 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve physical therapy to be provided by an out-of-network provider. You say that 
you really like this provider and would like to stay with them if possible. The Plan denied your request. The 
Plan says there are multiple physical therapy providers in-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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical 
therapy to be provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an MRI of the cervical spine provided on December 2, 2022, 
by an OON provider. 
 
You asked the Plan to pay for an MRI. You say that you are requesting reconsideration of the denied claim. 
The Plan denied your request. The Plan says that this service is not covered when received by an out-of-
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan contract says that the enrollees POS benefit does not 
apply to an out-of-network MRI. 
 
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 an MRI of the cervical spine provided on 
December 2, 2022, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical condition. There is no discussion of scoliosis of the lumbar spine with no documentation of the Cobb angle. 
There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in 
this patient. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the requested Vertiflex Superion interspinous 
spacer at L4-5, in this case, 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided by an out-of-network 
provider on January 9, 2023. 
 
You asked the Plan to pay for the lab services. You say that you are requesting an additional payment on this 
claim. The Plan denied your request. The Plan says that this claim was processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible which applies to out-of-network outpatient diagnostic 
testing and therapeutic services.  
 The items or services you asked the Plan to pay for fall within the outpatient diagnostic testing and therapeutic 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $500 deductible which applies to out-of-network outpatient diagnostic testing and therapeutic services. 
This cost sharing is a contractual obligation that had not been met at the time the lab services was received on 
January 9, 2023. Therefore, we decided that the Plan does not have to pay for the laboratory services provided 
by an out-of-network provider on January 9, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 additional physical therapy (PT) visits in addition to 
the 7 that were already approved. 
 
You asked the Plan to pre-approve the additional 5 PT visits. You say that the services are necessary for your 
condition and has been shown to reduce falls and fractures. The Plan denied your request. The Plan says the 
request for care is more than needed to treat your problems.  
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 the PT 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 you are receiving ongoing physical therapy to improve your balance. 
However, you are noted to have good balance overall with only slight gait deviation. The most recent therapy 
documentation indicates that you are walking your dog for an hour and a half without difficulty. You do not 
have significant limitation with regards to mobility and performing activities of daily living. Physical therapy 
now is primarily focusing on exercises to improve overall balance and strength. You are performing these 
exercises at home and can continue to do so. The services of a skilled physical therapist are not required to 
complete these exercises. 
 
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 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 5 additional physical therapy (PT) visits in addition to the 7 that were already approved.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the occupational therapy (OT) evaluation provided on September 6, 
2022. 
 
You asked the Plan to pay for the OT evaluation. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that the services are considered to be experimental or investigational. 
 
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 pay for the OT evaluation. Our reviewer says that 
the services were medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
Alzheimers dementia. The enrollee was assessed by occupational therapy to determine their fitness and safety 
with regards to operating a motor vehicle. Given their diagnosis and mild memory impairment this was 
medically appropriate for the enrollees condition and is not considered investigational or experimental in 
nature. Drivers evaluations are routinely performed by occupational therapists to assess the capability of an 
enrollee to safely operate a motor vehicle. Therefore, the occupational therapy evaluation was medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the OT evaluation have been met. Therefore, we decided that the Plan has to 
pay for the occupational therapy (OT) evaluation provided on September 6, 2022.  
 
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 pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is 
medically necessary. The Plan denied your request. The Plan says the requested Intracept procedure 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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary. Our 
physician reviewer found that the literature indicates that the Intracept procedure targets the basivertebral 
nerve for the relief of chronic verterbrogenic low back pain. Medicare guidelines consider this type of system 
unproven and not medically necessary. Large well-designed studies in the peer review scientific literature comparing stand-alone use of the Intracept device to established surgical decompression are needed.  
Published studies do not demonstrate any long-term health outcome advantage with the use of the Intracept as 
an alternative to standard surgical treatment. The review has determined that the requested Intracept 
procedure 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 Intracept procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occlusal guards (D9940). 
 
You asked the Plan to pre-approve the occlusal guards. You say that your dentist advised you that you grit your 
teeth at night and it is causing erosion as well as discomfort. You also say that the guard was approved by the 
plan 6 years ago. The Plan denied your request. The Plan says this service is not covered under the benefit 
package. 
 
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 
occlusal guards (D9940).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on December 17, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on December 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on July 25, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 
The two exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the 
inpatient or outpatient hospital POS code would be reported regardless of where the face-to-face service takes 
place. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with an outpatient POS code. The records do not support that the services were provided in an outpatient setting. The records show that the 
enrollee was an inpatient when the services were provided. Therefore, we decided that the Plan does not have 
to pay for the services provided on July 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Osteocel allograft. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is insufficient reliable evidence in the form of high-quality peer-reviewed medical 
literature to establish the safety and efficacy of the requested product for use in cervical fusion procedures. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this request is experimental, and more research is needed. Iliac crest bone graft is the gold standard. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Osteocel allograft.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 Reader. 
 
You asked the Plan to pre-approve the FreeStyle Libre 2 Reader. You say that the patient was testing seven 
times a day for uncontrolled blood sugar readings. 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 not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the FreeStyle Libre 2 Reader have not been met. Therefore, we decided that the Plan does not have to pre-
approve a FreeStyle Libre 2 Reader.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a caloric vestibular test (92537). 
 
You asked the Plan to waive the copayment for a caloric vestibular test. You say that you disagree with the 
copayment 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 $25 
copayment for Medicare-covered non-radiological diagnostic services.  
 
   
You have been asked to pay a $25 copayment for a caloric vestibular test. This item/service falls within the 
Medicare-covered non-radiological diagnostic 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 a caloric vestibular test (92537).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neuromuscular stimulator to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve a neuromuscular stimulator. You say that the requested stimulator is 
medically necessary. The Plan denied your request. The Plan says that this item is not covered by an out-of-
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 Plan contract 
also says that the enrollees POS benefit does not apply to out-of-network durable medical equipment. 
 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 neuromuscular stimulator to be provided by an OON provider.
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 is stable, has strong criteria 
for LTACH admission and is ready to transition to that level of care for medical management as well as starting 
an aggressive rehabilitation program. The Plan denied your request. The Plan says the enrollee is currently 
receiving medically necessary acute and/or critical care. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve buccal/labial frenectomy (D7961). 
 
You asked the Plan to pre-approve the dental service. You say that you cannot wear your dentures without this 
dental procedure being done. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because the buccal/labial frenectomy 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 pre-approve 
buccal/labial frenectomy (D7961).