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

 
We decided that the Plan does not have to pre-approve an advanced pneumatic compression device (E0652) 
with appliance. 
 
You asked the Plan to pre-approve pneumatic compression device E0652. You say that the enrollee meets 
coverage criteria for this device. The Plan denied your request. The Plan says measurements from the trial 
supporting that this device was effective were not submitted. 
 
The Plan follows Medicare rules. Medicare rules state that an advanced pneumatic compression device E0652 
may be covered after a trial of conservative therapy and a four-week documented trial of treatment with a basic 
device E0650 or E0651. 
 
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 pneumatic compression device E0652. 
Our reviewer says that the enrollee does not meet criteria for an E0652 pneumatic compression device. Our 
physician reviewer found there is no documentation of truncal edema in the records provided. The enrollee has 
been receiving manual lymphedema decompression therapy using taping, exercises, and elevation, but 
symptoms have not improved. A trial with this device was performed based on the pre-printed order signed by 
the physician; however, measurements supporting that this device was effective were not included. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pneumatic compression device E0652 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an advanced pneumatic compression device (E0652) with 
appliance.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occupational therapy.  
 
You asked the Plan to pre-approve occupational therapy. You say that you have established a treatment 
relationship with the requested provider. The Plan denied your request. The Plan says you must receive your 
care from a 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 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 
occupational therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2752) for tooth #29 and #30. 
 
You asked the Plan to pre-approve the crowns. You say that you are requesting reconsideration for the denial of 
crowns. The Plan denied your request. The Plan says the request does not meet the clinical criteria for a crown. 
 
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 crowns 
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 crowns. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the x-rays that are included are unreadable 
and are therefore undiagnostic. There are also no clinical notes to review stating why the crowns were 
necessary. Based on the clinical documentation included, crowns (D2752) for teeth numbers 29 and 30 are not 
medically necessary. 
 
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 crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve crowns (D2752) for tooth #29 and #30.
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 has tried BiPAP and failed. The 
enrollee has high carbon dioxide levels and there is a threat to the enrollee's health and life. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for a ventilator. 
 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 the service is not medically necessary. Our physician reviewer found the enrollee has COPD and chronic 
respiratory failure. The request for a ventilator is based on end-tidal carbon dioxide (ETCO2) & oxygen (O2) 
level during a overnight pulse oximetry and capnography study. Although the enrollee may have severe 
hypoxemia and hypercapnia, this testing is not standard of care for diagnosis. Also, there is no documented use 
or failure of BIPAP therapy. There are no pulmonary function tests (PFTs), arterial blood gas (ABG), or sleep 
study to support the request. Hence, a home ventilator is not indicated on documentation provided. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network walker provided on May 
02, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network walker. You say that you werent sure if this 
was the correct 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 20% 
coinsurance for durable medical equipment (DME) and related services. 
 
You have been asked to pay 20% coinsurance for an in-network walker. This item/service falls within the 
durable medical equipment (DME) and related 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. The total you owe is $19.80 ($99 allowed x 20% = $19.80). 
Therefore, we decided that the Plan does not have to waive the coinsurance for an in-network walker provided 
on May 02, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on December 3, 2021, to February 
2, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe that these services should be 
covered and paid. The Plan denied your request. The Plan says the dental services were received from an out-
of-network provider and are not covered by your supplemental benefits.  
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on December 3, 2021, to February 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abutment supported crown (D6058) and a custom 
fabricated abutment (D6057) for teeth #6 and #7. 
 
You asked the Plan to pay for D6058 and D6057. You say that you need this dental work. The Plan denied your 
request. The Plan says the rendered dental services are not covered benefits. 
 
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 pay for an 
abutment supported crown (D6058) and a custom fabricated abutment (D6057) for teeth #6 and #7.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device and the accessories 
provided on January 23, 2023, by an OON provider.  
 
You asked the Plan to pay for a compression device and the accessories. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says the service was not 
authorized. 
 
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 the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 at issue in this appeal. The Plan did not pre-approve the item at 
issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the 
Plan does not have to pay for a pneumatic compression device and the accessories provided on January 23, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies (A4452, A6196, A6252, A6446) 
provided on February 16, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that these items were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed items. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. No patient receipt 
or proof of delivery is included for the supply codes billed. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for wound care supplies (A4452, A6196, A6252, A6446) provided on February 16, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided on November 24, 2022, to 
November 30, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
enrollee was admitted for acute hypoxic respiratory failure in the setting of pneumonia. The Plan denied your 
request. The Plan says that the documentation does not clinically validate the diagnosis.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed inpatient services with diagnosis code J96.01, defined as acute respiratory failure with 
hypoxia. 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 inpatient hospital services at the 
DRG originally billed. Our physician reviewer found that the enrollee was admitted to the acute hospital with 
pneumonia and was treated with Augmentin. A chest x-ray showed bibasilar infiltrates and had respiratory 
syncytial virus. The enrollee also had leukocytosis. The enrollee was documented to be on nasal cannula for 
oxygen supplementation. Therefore, the diagnosis code is supported in the documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for the 
inpatient hospital services provided on November 24, 2022, to November 30, 2022, at the Diagnosis Related 
Group (DRG) originally billed.  
 
 
 
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), a cone beam (D0364), a 
crown (D2740), and core buildup (D2950) for tooth #30 provided on July 12, 2022, and August 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not understand your recent denial of 
benefit because you are covered up to the amount of $2,500. The Plan denied your request. The Plan says your 
benefit for the limited oral evaluation has already been exhausted and your annual dental maximum has already 
been exhausted. The cone beam 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, certain limitations apply. The record 
shows the Plan paid for a limited oral evaluation (D0140) on July 6, 2022; therefore, your benefit for the 
limited oral evaluation (D0140) on July 12, 2022, was exhausted on the date of service of July 6, 2023. The 
record shows the Plan paid $61 for dental services on July 6, 2022. On July 12, 2022, the Plan paid $677 for 
dental services. On August 16, 2022, the Plan paid $187 for dental services. On August 24, 2022, the Plan paid 
$75 for dental services. For the year of 2022 the Plan paid $1,000 ($61 paid + $677 paid + $187 paid + $75 
paid) for dental services; therefore, your annual dental maximum benefit was exhausted on the date of service 
of Aug 24, 2022. The cone beam is not covered under the Plans dental benefit. Therefore, we decided that the 
Plan does not have to pay for a limited oral evaluation (D0140), a cone beam (D0364), a crown (D2740), and 
core buildup (D2950) for tooth #30 provided on July 12, 2022, and August 24, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the MyoPro orthosis. 
 
You asked the Plan to pre-approve the MyoPro orthosis. You say that the item is medically necessary. The Plan 
denied your request. The Plan says that this item is considered experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MyoPro orthosis. Our reviewer says 
that the requested items is considered medically reasonable and necessary in this case. Our physician reviewer 
found the medical records support the enrollee's individual need for the requested orthosis. 
 
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 MyoPro orthosis have been met. Therefore, we decided that the Plan has to 
pre-approve the MyoPro orthosis.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management visits provided on March 21, 2023, to 
April 21, 2023. 
 
You asked the Plan to pay for pain management visits. You say that you were told when you enrolled in this 
plan that this provider was in-network. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for pain management visits 
provided on March 21, 2023, to April 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for non-covered wellness wallet service (WW999) and 
naturopathic services (WW030) provided from August 29, 2022, to October 20, 2022. 
 
You asked the Plan to reimburse for non-covered wellness wallet service (WW999) and naturopathic services 
(WW030). You say that the use of these daily herbal medicines is more than a supplement. You also say they 
are essential for the primary stated purpose to prevent, cure or diminish an illness or injury (Lyme disease in 
this case). The Plan denied your request. The Plan says this is not a covered service. 
 
The rules say that Medicare does not cover the services of a naturopath. However, the Plan offers a benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan pays for the 
services of a naturopath only when the services include immunizations, some counseling, manipulative therapy 
and dietary therapy.  
 
We looked at the file, Medicare rules and Plan rules. The Plan also has not chosen to offer supplemental 
coverage for vitamins/minerals, so they are not covered by the Wellness Wallet benefit. Based on this 
information, we decided that Medicare rules for coverage of herbal/sage supplementation have not been met. 
Therefore, we decided that the Plan does not have to reimburse for non-covered wellness wallet service 
(WW999) and naturopathic services (WW030) provided from August 29, 2022, to October 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) computed 
tomography (CT) brain amyloid. 
 
You asked the Plan to pre-approve the imaging. You say that the enrollee has been diagnosed with late onset 
dementia. You also say that this testing is necessary to differentiate between Alzheimer dementia and 
frontotemporal dementia. The Plan denied your request. The Plan says the enrollee is not enrolled in a coverage 
with evidence development (CED) study and therefore this cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that one PET amyloid-beta scan per patient will be 
covered through coverage with evidence development (CED).  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
positron emission tomography (PET) computed tomography (CT) brain amyloid.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-adjunctive, non-implanted continuous glucose 
monitor (CGM) receiver and supply allowance (E2103, A4239x12). 
 
You asked the Plan to pre-approve a Dexcom G7 receiver and sensors. You say that the Libre 3 has been 
inaccurate and wakes you up at night with false hypoglycemia alarms. The Plan denied your request. The Plan 
says only the preferred brand products listed in the EOC are covered.  
 
 The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a CGM receiver and sensors. Therefore, we decided that the Plan does not have to pre-approve a non-
adjunctive, non-implanted continuous glucose monitor (CGM) receiver and supply allowance (E2103, 
A4239x12).
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 would benefit from LTACH 
services to regain a maximum/prior level of functioning and the multidisciplinary approach to care. The Plan 
denied your request. The Plan says admission to an LTACH 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 that there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as the enrollee 
is not yet stable and as it would not be clinically advantageous 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.