Persius/hicric huggingface dataset:
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 tried and failed a 
BiPAP. You say that the enrollee requires the use of non-invasive home ventilator to treat the enrollee chronic 
respiratory condition. 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 although the 
enrollee has COPD and the spirometry test showed a forced expiratory volume (FEV1) of 40% of predicted, 
there is no diagnosis of thoracic restrictive disease or neuromuscular disease. While a BiPAP with a backup 
rate was prescribed on May 30,2023, a compliance download covering June 19, 2023, to September 16, 2023, 
showed only 6% of days for at least 4 hours a day the device used. Furthermore, there is no documentation of 
chronic carbon dioxide retention with an arterial blood gas analysis (ABG), done while stable. However, if 
there is chronic carbon dioxide retention the enrollee may benefit from a BiPAP with AVAPS during sleep as 
an outpatient. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myocardial strain test (93356). 
 
You asked the Plan to pre-approve a myocardial strain test. You say that the service is medically necessary. 
The Plan denied your request. The Plan says there is no Clinical documentation of need for myocardial strain 
test. 
 
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 a myocardial strain test. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found a transthoracic cardiac echo was ordered, but no results were provided and no discussion 
concerning the reason a stress echo would be required has been submitted. 
 
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 myocardial strain test have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a myocardial strain test (93356).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88112 provided on May 4, 2023. 
 
You asked the Plan to pay for procedure code 88112. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of procedure code 88112 have been met. 
Medical records, lab orders, and lab reports were not provided for review. Therefore, we decided that the Plan 
does not have to pay for procedure code 88112 provided on May 4, 2023.
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 without the equipment the enrollee 
could stay in the hospital or possibly die. 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 although the 
enrollee has presumed sarcoidosis and bronchiectasis, they had pleural effusions contributing to their 
hypercapnic respiratory failure. Also, the enrollee has responded and tolerated BIPAP and continued to require 
it during their hospitalization. Therefore, with no BiPAP failure noted the enrollee does not require AVAPS or 
a home ventilator at this time. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve home health care. You say that your daughter works for this company, and 
it would be a perfect opportunity to see her. The Plan denied your request. The Plan says this provider is out-
of-network with the Plan, and you can be treated within the Plan 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 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 
home health care to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body: endosteal 
implant (D6010) x4. 
 
You asked the Plan to pre-approve the dental services. You say that you need the implants to chew food 
normally and help aide in your stomach pain. The Plan denied your request. The Plan says this service is not 
covered under your 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. Surgical placement of implant 
body: endosteal implant is not covered under the Plans dental benefits. 
 
  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 the 
surgical placement of implant body: endosteal implant (D6010) x4.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Nalu peripheral nerve stimulator (PNS) (64555). 
 
You asked the Plan to pre-approve a Nalu peripheral nerve stimulator. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is not medically necessary. The enrollee has a lumbar spinal 
cord stimulator. 
 
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 a Nalu peripheral nerve stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found patients who have implanted cardiac or other neurostimulation systems 
should not use the Nalu neurostimulation system. Electrical pulses from the Nalu neurostimulation system may 
interact with the sensing operation of an implanted cardiac or neurostimulation system, causing the system to 
respond inappropriately. This enrollee has an implanted spinal cord neurostimulation 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 Nalu peripheral nerve stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Nalu peripheral nerve stimulator (PNS) (64555).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gum medication (D4381) for tooth #2, #19, and #30. 
 
You asked the Plan to pre-approve the dental services. You say that you are asking for an exception due to your 
medical condition. The Plan denied your request. The Plan says the denial of authorization for these services is 
correct, because the gum medication 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
gum medication (D4381) for tooth #2, #19, and #30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the semi-precision attachment abutment (D6052) for 
tooth #3, #6, #11, and #14. 
 
You asked the Plan to pre-approve the dental services. You say that you had surgery in your mouth, and you 
need to fix your teeth from the accident, and this is not a dental issue it is a medical issue. You also have TMJ. 
The Plan denied your request. The Plan says the denial of authorization for these services is correct, because 
the semi-precision attachment abutment 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. 
 
The requested semi-precision abutments in dispute meets the Medicare definition of dental, since it is a service 
which involved the care and treatment of teeth or structures directly supporting the teeth. The semi-precision 
abutments do not fall under any of Medicare exceptions for coverage of non-routine dental care. 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 the semi-precision 
attachment abutment (D6052) for tooth #3, #6, #11, and #14.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional occupational therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that 10 additional occupational therapy visits 
are medically necessary. The Plan denied your request. The Plan says 10 additional occupational therapy visits 
are not reasonable and 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 the therapy services. 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 the enrollee is noted to require maximum assistance with feeding as 
well as most daily activities. The enrollee receives assistance in a long-term care facility. While occupational 
therapy may be indicated to improve the enrollee's function with feedings, there is a lack of documentation 
indicating objective improvement and progress with therapy. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional occupational therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported crown - porcelain fused to high 
noble alloys (D6066), and custom fabricated abutment  includes placement (D6057). 
 
You asked the Plan to pre-approve the implant supported crown and custom fabricated abutment. You say that 
there is a gap between your teeth and it is affecting your biting and eating and is uncomfortable. The Plan 
denied your request. The Plan says this service is not covered in your dental benefit. 
 
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an implant 
supported crown - porcelain fused to high noble alloys (D6066), and custom fabricated abutment  includes 
placement (D6057).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5213). 
 
You asked the Plan to pre-approve the dental service. You say that the partial denture you received in May of 
2022 is loose and will not stay in your mouth. The Plan denied your request. The Plan says your benefit for the 
requested 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 maxillary partial denture was exhausted on date of service May 3, 2022. Therefore, 
we decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5213).
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 clearly meets long term 
acute care hospital criteria and feels strongly that they should be authorized for the services. The Plan denied 
your request. The Plan says this 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 transfer to the LTACH is not medically necessary as the enrollee does not yet have a 
stable feeding source and as it would not be clinically appropriate at this time. Completion of treatment at the 
current facility is recommended.   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis (Minuteman device) (22612). 
 
You asked the Plan to pre-approve the Minuteman device. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary as this device is intended for use with bone 
graft material and is not intended for stand-alone use. 
 
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 Minuteman device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Minuteman device is intended for use with bone graft material and is not intended 
for stand-alone use. In addition, fusion indications within guidelines/literature for (existing or potential 
intraoperative) instability have not been documented and/or met in this case. In addition, there are multiple 
alternate pain generators plausibly significantly contributing to the clinical condition that have not been fully 
documented as having been excluded and/or ruled out. No compelling rationale is presented, or extenuating 
circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve arthrodesis (Minuteman device) (22612).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cyanocobalamin. 
 
You asked the Plan to pre-approve Cyanocobalamin. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cyanocobalamin.  Benefits for Cyanocobalamin may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on 
January 17, 2023, to April 5, 2023. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you disagree 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 $95 
copayment and a $195 copayment for outpatient hospital services.  
 
You have been asked to pay a $95 copayment and a $195 copayment for outpatient hospital services/ 
Medicare-covered outpatient hospital facility visit. However, since the allowed amount is less than the standard 
copayment, you only owe $70 per visit for dates January 24, 2023, to April 5, 2023. You are being asked to pay $195 copayment for January 17, 2023. However, since the allowed amount is less than the standard copayment, 
you only owe $100.60. The total amount you are being asked to pay is $450.60 ($70 + $70 + $70 + $70 + $70 
+ $100.60 = $450.60). This item/service falls within the outpatient hospital 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 outpatient hospital services provided on January 17, 2023, 
to April 5, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a custom socket and K3-level flex-walk style foot with multiaxial 
rotation unit (L5981, L5986).  
 
You asked the Plan to pre-approve a custom socket and K3-level flex-walk style foot with multiaxial rotation 
unit. You say that the item is medically necessary. The Plan denied your request. The Plan says that the item is 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of knee. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 custom socket and K3-level flex-walk 
style foot with multiaxial rotation unit. Our reviewer says that the item is medically necessary. Our physician 
reviewer found the medical records show the enrollee as a K3 ambulator with medical need for the requested 
item. 
 
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 custom socket and K3-level flex-walk style foot with multiaxial rotation unit 
have been met. Therefore, we decided that the Plan has to pre-approve a custom socket and K3-level flex-walk 
style foot with multiaxial rotation unit (L5981, L5986).   
 
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.