Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulmonary rehabilitation. 
 
You asked the Plan to pre-approve pulmonary rehabilitation. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary PR programs 
for those with moderate to very severe COPD. There must be a referral from the doctor treating the disease. 
The services must be provided in a doctors office or an outpatient hospital setting. The PR program must 
include specific components. Benefits are limited to a maximum of 36 visits, with an additional 36 visits if 
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 pulmonary rehabilitation. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found pulmonary rehabilitation is 
not medically necessary because Medicare criteria are not met. This enrollee has asthma, pulmonary 
hypertension, and obstructive sleep apnea. Pulmonary function tests are described as showing moderate airflow 
obstruction, with a forced expiratory volume (FEV1) of 56% of predicted, and a positive bronchodilator 
challenge test. There is no diagnosis of chronic obstructive pulmonary disease (COPD) or 
emphysema. Medicare does not cover pulmonary rehabilitation for enrollees with asthma. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pulmonary rehabilitation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve pulmonary rehabilitation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6531. 
 
You asked the Plan to pre-approve the compression stockings. You say that the requested compression 
stockings are medically necessary for the enrollee. The Plan denied your request. The Plan says the Medicare 
criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means 
that the enrollee does not have a medical condition for which compression stockings can be covered or paid for 
by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings 
identified with code A6531.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasonic guidance for placement of radiation therapy 
fields (G6001). 
 
You asked the Plan to pre-approve the ultrasonic guidance. You say that you would like this to be reviewed, 
reprocessed, and approved according to the contract as a medical necessity. The Plan denied your request. The 
Plan says the requested service is not covered by Medicare or the Health Plan. 
 
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 ultrasonic guidance. Our reviewer 
says that ultrasonic guidance for placement of radiation therapy fields is not medically reasonable and 
necessary for this type of skin tumors. 
 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 ultrasonic guidance have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ultrasonic guidance for placement of radiation therapy fields (G6001).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study (95810). 
 
You asked the Plan to pre-approve a sleep study. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. The testing to diagnose obstructive sleep apnea can 
be safely provided with a Home Sleep Apnea Test (HSAT). 
 
The Plan follows Medicare rules. Medicare rules say that sleep studies can be covered when specific criteria 
are met. 
 
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 sleep study. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee has symptoms suggestive of 
obstructive sleep apnea, including excessive daytime sleepiness. The body mass index (BMI) is 36. The 
enrollee does not have severe heart failure or lung disease, or other conditions that would preclude a home 
sleep study. It would be reasonable to begin with a home sleep study, and if OSA is confirmed, prescribe auto 
titrating CPAP. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study (95810).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interim crowns (D2799), pontics (D6245), retainer 
crowns (D6740), application of desensitizing medicament (D9910), and core buildups (D2950). 
 
You asked the Plan to pre-approve D2799, D6245, D6740, D9910, and D2950. You say that you do not 
understand why this dental work is being denied. The Plan denied your request. The Plan says these services 
have been correctly denied. 
 
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, D2799, D6245, D6740, and D9910 are 
not among those covered under this benefit. The rules for D2950 have not been met. Therefore, we decided that the Plan does not have to pre-approve interim crowns (D2799), pontics (D6245), retainer crowns (D6740), 
application of desensitizing medicament (D9910), and core buildups (D2950).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
for your medical appointments. The Plan denied your request. The Plan says this request will exceed the 
maximum number of transportation trips allowed per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that this request will exceed the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an implantable, insertable, and wearable cardiac device 
evaluation provided on May 18, 2023. 
 
You asked the Plan to pay for the implantable, insertable, and wearable cardiac device evaluation. You say that 
the services were medically necessary. The Plan denied your request. The Plan says 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 says that the Plan has also determined that these services are not urgent or emergent, nor were 
they approved in advance. 
 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 implantable, insertable, and wearable cardiac device 
evaluation provided on May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a routine eye examination (92014) provided on April 3, 2023. 
 
You asked the Plan to pay for a routine eye examination (92014). You say that the coding on the claim is 
correct. You also say that the medical documentation supports this is a medical claim, and you would like it 
reprocessed. The Plan denied your request. The Plan says that the claim was billed with a primary diagnosis 
code that is considered a routine diagnosis code. The Plan also says that the services should be billed to the 
Plan's vision vendor. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan denied the appeal saying the primary diagnosis code was a routine 
diagnosis code, and the services should be billed to the Plan vision vendor. However, the Plan did not provide 
any other reason for the denial. This denial reason is not a valid denial reason. The Plan contracts with the 
vision vendor, so it is still the Plan's responsibility to make sure the claim goes where it needs to go and get 
processed. Therefore, we decided that the Plan has to pay for a routine eye examination (92014) provided on 
April 3, 2023.  
 
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 the crown (D2740) for tooth number 30, core buildup 
(D2950) and gingivectomy (D4212) provided on April 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed your tooth fixed due to all the pain. 
The Plan denied your request. The Plan says that these services are either not covered or your benefit for the 
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 D2740 was exhausted on date of service February 21, 2019. Additionally, D2950 and 
D4212 are not covered under any circumstance. Therefore, we decided that the Plan does not have to pay for 
the crown (D2740) for tooth number 30, core buildup (D2950) and gingivectomy (D4212) provided on April 
26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve the dental service. You say that your gums are hurting and it is hard to 
chew. 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 the Plan paid for a partial lower denture (D5214) on March 24, 2023; therefore, your benefit for the 
requested item or service was exhausted on the date of service of March 24, 2023. Therefore, we decided that 
the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E2311, E2313, E2377, E0955, E1007, 
E1012, E1028, E2300, E2359, E2607, E2620, and K0040). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that you cannot move and need the wheelchair to help you get around. You also say that without this, 
you are unable to take care of your everyday needs and life functions. The Plan denied your request. The Plan 
says you do not have a medical need for multiple power options included with K0861 group 3 power 
wheelchair. The Plan also says the electronic connection, harness, and expandable controller cannot be covered 
as it is not medically necessary to control the three requested power options through the joystick (drive 
interface). 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. 
 
 
 
 
 
 
 
 
 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 group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that you do not meet the criteria for coverage. Our 
physician reviewer found although you have a diagnosis eligible for a group 3 power wheelchair, provided 
records from your treating physician do not support that you are high risk for skin breakdown, have a history of 
pressure ulcer(s) or have had skin flap surgery. Records from your physician do not document that you perform 
bladder self-catheterization or that you have increased muscle tone or spasticity to meet criteria for the power 
tilt and/or recline and thus the multiple power option base. Our reviewer also found that as the requested 
wheelchair base does not meet Medicare coverage criteria, none of the requested accessories (codes E2311, 
E2313, E2377, E0955, E1007, E1012, E1028, E2300, E2359, E2607, E2620, and K0040) are covered.  
 
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 group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power 
wheelchair with multiple power options (K0861) and additional items and accessories (codes E2311, E2313, 
E2377, E0955, E1007, E1012, E1028, E2300, E2359, E2607, E2620, and K0040).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that you need a CGM. The Plan denied your request. The 
Plan says the medical criteria for a CGM has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes, 
use insulin or have a history of problematic hypoglycemia. Based on this information, we decided that 
Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3020). 
 
You asked the Plan to pre-approve the foot orthotics. You say that you are not a diabetic but were prescribed 
orthotics insoles/inserts before enrolling with the Plan. You also say that you have worn the orthotics since you 
were a young adult. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an implantable, insertable, and wearable cardiac device 
evaluation provided on May 25, 2023. 
 
You asked the Plan to pay for the implantable, insertable, and wearable cardiac device evaluation. You say that 
the services were medically necessary. The Plan denied your request. The Plan says 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 says that the Plan has also determined that these services are not urgent or emergent, nor were 
they approved in advance. 
 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 implantable, insertable, and wearable cardiac device 
evaluation provided on May 25, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided on May 31, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for SNF. You say that the records provided support the services. The Plan denied 
your request. The Plan says these services can be obtained by an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided on 
May 31, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete denture - mandibular (D5120), and complete 
denture - maxillary (D5110) provided on June 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that this is the third bill you have been sent and you 
have not picked up the teeth. The Plan denied your request. The Plan says your benefit for the complete 
dentures - mandibular and  maxillary 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 complete dentures - mandibular and maxillary was exhausted on date of service May 
2, 2022. Therefore, we decided that the Plan does not have to pay for the complete denture - mandibular 
(D5120), and complete denture - maxillary (D5110) provided on June 12, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wireless capsule endoscopy (91110). 
 You asked the Plan to pre-approve wireless capsule endoscopy. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that wireless capsule endoscopy is covered when specific 
criteria are met. 
 
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 wireless capsule endoscopy. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that the wireless capsule endoscopy at issue in this case meets all 
Medicare criteria for medically reasonable and necessary for the enrollee.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wireless capsule endoscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve wireless capsule endoscopy (91110).