Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
January 22, 2023, through February 13, 2023.. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says a PCD is not covered for preventative 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 on January 22, 2023, through February 13, 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 you cannot be sent home without the 
home ventilator machine. 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 you have 
COPD and chronic respiratory failure with COPD exacerbation. Since being admitted to the hospital you 
showed improvements with BiPAP therapy. Hence, a BiPAP would be a reasonable starting point for therapy 
per the documentation, not a home ventilator. Therefore, a BiPAP with or without AVAPS is appropriate initial 
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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a water circulating heat pad with pump (E0217) provided on 
January 22, 2023, through February 13, 2023. 
 
You asked the Plan to pay for a water circulating heat pad with pump. You say that the item was medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that if code E0215 or E0217 is provided it will be 
denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for a water circulating heat pad with pump (E0217) provided on January 22, 2023, 
through February 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical each additional radiographic image 
(D0230) provided on May 3, 2023. 
 
You asked the Plan to pay for the intraoral - periapical each additional radiographic image. You say that you 
only have 7 bottom front teeth therefore you cannot have a bitewing x-ray. You also say that it is not 
reasonable to charge $68 when you only have 7 bottom teeth. The Plan denied your request. The Plan says your 
benefit for the intraoral - periapical each additional radiographic image has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested services was exhausted on date of service May 3, 2023.  Therefore, we decided that the Plan does not have to pay for an intraoral - periapical each additional 
radiographic image (D0230) provided on May 3, 2023.
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 physical therapy services to gain their strength back before returning home. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nulojix (belatacept) (J0485). 
 
You asked the Plan to pre-approve Nulojix (belatacept). You say that this is a life-saving medication for the 
enrollee since it has been clinically proven to prevent acute rejection and loss of their transplanted lungs while 
preserving renal function. The Plan denied your request. The Plan says the diagnosis provided, Lung transplant 
status, is not a medically accepted use for Nulojix. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Nulojix (belatacept). Our reviewer says 
that this request is not medically reasonable and necessary. Our physician reviewer found the requested use of 
Nulojix (belatacept) (J0485) is not FDA-approved for the enrollees diagnosis. Our reviewer also found that its 
use is not supported by one of the major drug compendia or by clinical research that appears in a Centers for 
Medicare & Medicaid Services (CMS) approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nulojix (belatacept) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Nulojix (belatacept) (J0485).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper denture (D5110), and complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 23, 2022. 
Therefore, we decided that the Plan does not have to pre-approve complete upper denture (D5110), and complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), provided on 
March 27, 2023. 
 
You asked the Plan to pay more for the extraction. You say that after your check-up in February you were told 
tooth 19 look infected. You also say that you thought your current HMO plan might have enough dental so you 
switched to a PPO plan with dental coverage. 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 an extraction, erupted tooth requiring 
removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated 
(D7210), provided on March 27, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for noncovered ambulance mileage (for miles traveled beyond 
the closest appropriate facility) provided on April 22, 2023. 
 
You asked the Plan to pay for noncovered ambulance mileage (for miles traveled beyond the closest 
appropriate facility). You say that the services were ordered by your physician and were medically necessary. 
The Plan denied your request. The Plan says Medicare states that ambulance miles beyond the closest 
appropriate facility cannot be billed to Medicare. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of noncovered ambulance mileage (for miles traveled beyond the closest appropriate facility) have 
not been met. Therefore, we decided that the Plan does not have to pay for noncovered ambulance mileage (for 
miles traveled beyond the closest appropriate facility) provided on April 22, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing (G0299 x6). 
 You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found clinical 
documentation does not specify any acute clinical status change, medication or plan of care change and 
sufficient instruction on chronic medical conditions has been documented. The records do not show that 6 
additional home health skilled nursing visits are required to effectively provide treatment, care, and/or services 
in order to improve your condition, or to establish/perform a maintenance program to maintain the your 
condition and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing (G0299 x6).
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 these services are medically necessary. 
The Plan denied your request. The Plan says the enrollee can safely receive care in another setting.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current care setting. 
 
 
 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) scan of both breasts. 
 
You asked the Plan to pre-approve the MRI . You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee does not meet the criteria for approval. 
 
The Plan follows Medicare rules. Medicare rules say that they cover services that 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 MRI. Our reviewer says that the 
MRI is medically necessary. Our physician reviewer found the enrollee has documented ataxia-telangiectasia 
mutated (ATM) genetic mutation which has been associated with up to 40% lifetime risk of breast cancer. As 
the local coverage determination (LCD) guidelines require a greater than 20% lifetime risk to qualify for a 
yearly MRI the enrollee does meet those qualifications. Therefore, the services should be approved. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
a magnetic resonance imaging (MRI) scan of both breasts.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ambulance service to and from your doctors 
appointment. 
 
You asked the Plan to pre-approve the non-emergency ambulance transport. You say that the services are 
medically necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  The services you have asked the Plan to pre-approve are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pre-approve ambulance service to and from your doctors 
appointment.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and a drug test provided on May 18, 2023. 
 
You asked the Plan to pay for the office visit and drug test. You say that this provider is in-network with the 
Plan. The Plan denied your request. The Plan says this provider is a non-network provider who does not work 
with the member's health Plan. The Plan requires utilization of network providers when possible and available 
and requires authorization for certain services. No medical necessity for an out-of-network provider such as an 
urgent or an emergent situation that has been documented.   
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit and a drug test provided on May 18, 2023.
Appeal type: Surgery
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 enrollee has tried and failed 
conservative treatment without relief and the surgery is medically necessary.  The Plan denied your request. 
The Plan says the Intracept procedure is not medically necessary. The Plan says the Intracept procedure is 
considered experimental and investigational.  
 
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 surgery is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without facet 
degenerative joint disease or foraminal stenosis. This means that the cause of pain is not clear.  
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee has been falling and has weakness in 
the right leg. The Plan denied your request. The Plan says the enrollee's medical needs can be met where they 
are now.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled SNF 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency medical transportation to and from 
therapeutic horseback riding. 
 
You asked the Plan to pre-approve non-emergency medical transportation. You say that the enrollee needs this 
transportation for therapy to help with their multiple sclerosis. The Plan denied your request. The Plan says the 
transportation is not approved as it is considered not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency medical transportation. 
Our reviewer says that the medical transport is not apparently necessary. Our physician reviewer found it is not 
clear why other transport methods are contraindicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergency medical transportation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency medical transportation to and from 
therapeutic horseback riding.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were referred here so it should be covered. 
The Plan denied your request. The Plan says your $6,000 annual maximum has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pay for dental services provided on April 10, 2023.