Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve peripheral nerve stimulator. 
 
You asked the Plan to pre-approve peripheral nerve stimulator. You say that the peripheral nerve stimulator 
will help the member with her chronic pain. The Plan denied your request. The Plan says evidence is 
insufficient to support the long-term efficacy of this modality of treatment. 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 peripheral nerve stimulator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found this is the subject of 
ongoing clinical trials and is considered experimental/ investigation. 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 peripheral nerve stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve peripheral nerve stimulator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for a humerus fracture and a pelvic fracture after a fall.  Medical problems are stable. There are 
no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive periodontal evaluation (D0180) 
provided on April 19, 2023. 
 
You asked the Plan to pay more 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 you are responsible for any charged amount 
above the Plans cost-sharing amount when your services are received from an out-of-network provider.  
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the comprehensive periodontal evaluation 
(D0180) provided on April 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #20, #21, #22, #27, and #28. 
 
You asked the Plan to pre-approve the dental services. You say that without the crowns you will not be able to 
eat. The Plan denied your request. The Plan says the x-rays provided do not show that the anterior teeth and the 
premolars have enough tooth structure missing to meet the criteria for approval for the crowns. 
 
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 Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
  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 dental services. Our reviewer says 
that the requested dental services are not medically reasonable and necessary. Our physician reviewer found 
that the requested crowns would not be necessary for any of the teeth in question as there is no showing of 
substantial structural breakdown on tooth #20, #21, #22, #27, or #28. Crowns may be considered necessary 
where there is substantial breakdown of about 50% of the clinical crown and the tooth is unable to be properly 
restored with conventional materials. In this instance there is adequate structure to allow for conventional 
restorations if needed, and crowns would not be medically necessary. 
 
There is no clear breakdown of tooth structure that would require full coverage crowns. The Plan does not 
allow for crowns to restore teeth that are worn down and not by the action of caries or trauma. As there is 
substantial tooth structure remaining on all the proposed teeth, crowns would not be indicated and would not 
meet the Plan's criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2750) for tooth #20, #21, #22, #27, and #28.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided from 
September 17, 2022, to October 7, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. The Plan denied your request. The Plan says 
this is not covered for preventive services. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided from September 17, 2022, to October 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reblozyl (J0896). 
 
You asked the Plan to pre-approve Reblozyl. You say that you are requesting an adverse determination. The 
Plan denied your request. The Plan says the use of this drug/regimen is not reasonable and necessary. 
 
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 Reblozyl. Our reviewer says that 
Reblozyl is not medically reasonable and necessary. Our physician reviewer found the enrollee has a diagnosis 
of myelodysplastic syndrome with pancytopenia without documentation of ringed sideroblasts. The FDA has 
not stated that the requested drug is indicated for the enrollee's condition. Our reviewer found that the Medicare 
approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation.  No literature from Medicare approved cancer journals were submitted for review. 
Our physician reviewer also found that the elements of the coverage criteria are not satisfied, and the requested 
service cannot be 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 Reblozyl have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Reblozyl (J0896).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the inpatient hospital stays provided from 
May 12, 2022, to June 15, 2022. 
 
You asked the Plan to waive the copayments for the inpatient hospital stays. You say that you would like for 
the services to be fully covered. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $390 copayment per day, for days 1 to 4 and a $0 copayment per day for days 5 to 365 for each 
stay.  
 The enrollee has been asked to pay a $390 copayment per day, for days 1 to 4 of the inpatient hospital stay 
provided from May 12, 2022, to May 21, 2022. The amount you owe for this stay is $1,560 ($390 copayment x 
4 days = $1,560). The enrollee has also been asked to pay a $390 copayment per day, for days 1 to 4 of the 
inpatient hospital stay provided from June 10, 2022, to June 15, 2022. The amount you owe for this stay is 
$1,560 ($390 copayment x 4 days = $1,560). These services fall within the inpatient hospital care benefit 
category. This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayments for the inpatient hospital stays 
provided from May 12, 2022, to June 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the growth removal surgery and each drug 
injection provided on June 12, 2023. 
 
You asked the Plan to waive the cost share for the growth removal surgery and each drug injection. You say 
that you are on a fixed income and cannot afford this cost sharing. 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 $285 
copayment for in-network outpatient surgery provided at an outpatient hospital. Your contract with the Plan 
also clearly says that you must 20% coinsurance for in-network Medicare Part B drugs.  
 
Date of Service CPT Code Allowed Amount Copayment Coinsurance 
June 12, 2023 21555 $2,597.40 $285 - 
June 12, 2023 J0690 $6.06 - $1.21 
June 12, 2023 J2250 $0.51 - $0.10 
June 12, 2023 J2250 $2.03 - $0.41 
June 12, 2023 J2704 $8.11 - $1.62 
June 12, 2023 J2704 $5.80 - $1.16 
June 12, 2023 J3010 $0.90 - $0.18 
June 12, 2023 J7120 $13.10 - $2.62 
Total $292.30 
 
You have been asked to pay a $285 copayment for the growth removal surgery. This item/service falls within 
the outpatient surgery benefit category. You have also been asked to pay 20% coinsurance for each drug 
injection. 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 cost share for the growth removal surgery and each drug 
injection provided on June 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) provided on March 27, 2023. 
 
You asked the Plan to pay 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 enrollee has exhausted the allowable benefit for 
the hearing aids provided in this case.  
 
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.   
 
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 there is a $2,000 
allowance for hearing aids every three years. The record shows that the enrollee received hearing aids on 
March 30, 2021, less than three years prior, which were paid for by the Plan.  
  
 
 
 
Therefore, the enrollee has exhausted the allowable benefit for these items. Therefore, we decided that the Plan 
does not have to pay for the hearing aids (V5261) provided on March 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment (DME) to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve DME. You say that the supplies should be covered do to medically 
necessary. The Plan denied your request. The Plan says this is available 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 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 
durable medical equipment (DME) to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that medical records have been submitted to show 
medical necessity. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the member is only noted to have a mixed 
vascular dementia/AD. The records did not support a diagnosis of both AD and FTD. There was no indication 
that FTD was suspected in this case. This service would not meet criteria for coverage. 
 
 
  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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee does not need a BiPAP machine 
but needs a non-invasive ventilator, it is removing carbon dioxide (CO2) from their lungs. The Plan denied 
your request. The Plan says this request is not covered. 
 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. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found this patient has severe COPD 
with chronic CO2 retention, as documented on an arterial blood gas done as an outpatient on June 27, 2023.  
There is no diagnosis of thoracic restrictive disease or neuromuscular disease. Our reviewer found that the 
patient was previously on BiPAP at home, according to the visit note of February 26, 2019. A more recent note 
on September 12, 2023, indicates that the patient's BiPAP is not working. Our physician reviewer also found 
that the records do not show that the patient has been tried on BiPAP with average volume-assured pressure 
support (AVAPS) at home, or that BiPAP has failed to treat the CO2 retention 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the enrollee 
to receive the needed care. The Plan denied your request. The Plan says the enrollee does not meet the criteria 
for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on March 20, 2023. 
 You asked the Plan to pay for the urine PCR panel testing. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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. 
 
The test at issue in this appeal, the urine PCR panel testing, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the urine polymerase chain reaction (PCR) panel testing provided on March 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx testing (0037U) provided on April 
21, 2023. 
 
You asked the Plan to pay for the FoundationOne CDx testing. You say that this testing was medically 
necessary.  The Plan denied your request. The Plan says you do not meet criteria for coverage of this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that this testing is covered when the enrollee has 
either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
We looked at the file and Medicare rules. In this case the record does not show that the enrollee has either 
recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. Based on this information, we 
decided that Medicare rules for coverage of the FoundationOne CDx testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the FoundationOne CDx testing (0037U) provided on April 21, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on May 19, 2023. 
 
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 (99203) provided on May 19, 2023.